Progressive Steps Inc. Foster Care Application

Progressive Steps Inc. Foster Care Application
Progressive Steps Inc.
3100 Lord Baltimore Drive Suite 205
Windsor Mill , Maryland 21244
Date:

Month Day Year
Date
Check one:

Treatment Foster Care Respite
APPLICANT 1:
Name:

First Name Middle Name Last Name
Date of Birth:

Month Day Year
Date
Social Security #:
Race:
Citizenship:
Martial Status:
Occupation:
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number:
Work Number:
Cell Number:

PEOPLE LIVING IN YOUR HOME:

What do you/or your family have to contribute that would make you a good foster home?
What characteristics of a child would your family most readily accept? (check all that apply):

Multiple physical Medically fragile Emotional disorders Behavior problems
Changes will occur within your family once a foster child is placed in your home – how will your family respond?
Does any household member have a physical, mental or chronic illness:

Yes No
List and explain:

Please provide a driver’s license # and expiration for all drivers in the home (besides applicants):
Name:

First Name Last Name
License#:
Expiration Date:

Month Day Year
Date
APPLICANT 1:
Do you own a car?

Yes No
Make:
Model:
Year:
Driver’s license# (or indicate non-drive):
Expiration Date:

Month Day Year
Date
APPLICANT 2:
Do you own a car?

Yes No
Make:
Model:
Year:
Driver’s license# (or indicate non-drive):
Expiration Date:

Month Day Year
Date

Please list three professional references and one family member.
Name:

First Name Last Name
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Home:
Work:
Ext:
Name:

First Name Last Name
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Home:
Work:
Ext:
Name:

First Name Last Name
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Home:
Work:
Ext:
Please Check:

I hereby apply to become a Treatment Foster Parent(s) in Progressive Steps, Inc. Treatment Foster Care Program.
Signature:

Clear
Signature:

Clear
Progressive Steps Inc.
Treatment Foster Care
3100 Lord Baltimore Drive Suite 205
Windsor Mill, Maryland 21244
Should be Empty:

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APPLICANT 1: