MISSOURI DEPARTMENT OF SOCIAL SERVICES
|[pic] |MISSOURI DEPARTMENT OF SOCIAL SERVICES |
| |CHILDREN’S DIVISION |
| |APPLICATION TO PROVIDE RESPITE CARE |
|Name |Date of Birth |SSN |
| | | |
|Spouse |Date of Birth |SSN |
| | | |
|Home address: |
| |
|Telephone number: |
| |
|Email address: |
| |
|Please list other persons residing in the home, date of birth, relationship to head of household, and Social Security Number. Attach additional pages, if necessary. |
|Name |Date of Birth |Relationship to Head of Household |SSN |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
|Please respond to the following questions: |
|1. What is your understanding of the Children’s Division Respite Care program? |
| |
|2. What motivated you to become a Children’s Division Respite Care provider? |
| |
|3. What child care experience do you have? |
| |
|4. Are you currently providing care for other unrelated children? If yes, how many unrelated children are you providing care for in your home/facility? |
| |
|5. What is your understanding of Children’s Division regulations regarding corporal punishment? |
| |
|6. What is your understanding of the laws governing confidentiality of foster children placed in your home? |
| |
|I (We), the undersigned, certify that I (we) have received an explanation of the Respite Care program as provided through the Children's Division and understand the |
|terms as stated in this application. |
|Signature |Date |Signature |Date |
| | | | |
|This is to certify that I have completed the walk through of the applicant’s home and completed the Respite Care Provider Checklist, CS-RC-2. |
|Children's Service Worker Signature |Date |
|This is to certify that I have provided an explanation of the Respite Care Program as provided through the Children's Division to the Respite Care applicant. |
|Children's Service Worker Signature |Date |
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