Sample Foster/Adoption Application

FOSTER or ADOPTION (circle one) APPLICATION

PROTECTIVE SERVICES DIVISION

ALL INFORMATION IS STRICTLY CONFIDENTIAL

1. Applicant’s Name	Last	First	MI	Work Telephone
2. Applicant’s Name	Last	First	MI	Work Telephone
Home Address	No. and street, R.RT.	City	State Zip	Work Telephone

Mailing Address (if different from above)

Directions for finding home:

First Applicant

Second Applicant

BIRTH PLACE

DATE OF BIRTH

BIRTH PLACE

DATE OF BIRTH

Country Ancestors came from
Primary Language Spoken in the Home
Other Language Spoken in the Home
Religion (if applicable)

PHYSICAL DESCRIPTION	Gender	Height	Weight	Gender	Height	Weight
	Hair Color	Eye Color	Skin Color	Hair Color	Eye Color	Skin Color
Education Last Grade / Degrees Completed	Grammar	High School	Collage	Grammar	High School	Collage
Military Service	Branch	Length of Service	Type of Discharge	Branch	Length of Service	Type of Discharge

EMPLOYMENT

List your employment history for the last 3 years Include address and telephone numbers

OCCUPATION

Present Employer How long at this job? Gross Salary $

OCCUPATION

Present Employer How long at this job? Gross Salary $

Previous Job How Long Employed?

SOCIAL SECURITY NUMBER

INSURANCE COVERAGE	Insurance Company Name
Automobile
Hospitalization
Life
Other Insurance:	Other Assets:

HOME INFORMATION

( ) House ( ) Apartment ( ) Mobile Home	Number of Bedrooms?
Rent per month $	Mortgage Payment per Month $

How Long have you lived at your current address? ____________years ____________months

Previous Addresses for the last five (5) years	Dates - From and to

MARRIAGE HISTORY

PRESENT MARRAGE Attach copy of license/certificate	Where did you get married? Placed - Town, Country, State	Date of present marriage
PREVIOUS MARRIAGES (Attach copies of Divorce Decree)	FIRST APPLICANT	SECOND APPLICANT
To Whom Married?
Date and Place
Date and Place of Divorce
Date of Spouse’s Death
PREVIOUS MARRIAGES (Attach copies of Divorce Decree)	FIRST APPLICANT	SECOND APPLICANT

To Whom Married?
Date and Place
Date and Place of Divorce
Date of Spouse’s Death

IF MORE THAN TWO (2) PREVIOUS MARRIAGES, PLEASE LIST ON SEPARATE SHEET OF PAPER
FRIST APPLICANT’S FAMILY

Name	Mailing Address	Age	Health	Occupation
Father
Mother
Sibling
Sibling
Sibling
Sibling
Sibling

SECOND APPLICANT’S FAMILY

Name	Mailing Address	Age	Health	Occupation
Father
Mother
Sibling
Sibling
Sibling
Sibling
Sibling

CHILDREN IN THE HOME

Name and Social Security Number of child	Birth date	Occupation or School Grade	Birth or adopted child

CHILDREN OUT OF THE HOME

Name of child	COMPLETE Address and Phone	Birth date	Occupation or School Grade	Birth or Adopted child

IF ADDITIONAL ROOM IS NEEDED TO LIST FAMILY MEMBERS, USE BACK OF PAGE

CHILDREN DECEASED

Name	Date

OTHERS LIVING IN THE HOME - Adults and Children

Name	Relationship	Birth date	Occupation or School Grade

HAVE YOU EVER BEEN:

	First Applicant	Second Applicant
Arrested as a Juvenile?	Yes( ) No ( )	Yes( ) No ( )
Arrested as an adult?	Yes( ) No ( )	Yes( ) No ( )
Received Psychological psychiatric Treatment	Yes( ) No ( )	Yes( ) No ( )
Previously Studied for Foster Care or Adoption	Yes( ) No ( )	Yes( ) No ( )

If there is a YES answer to any of the above four questions, please explain circumstances
please attach a separate sheet if needed.

NOTE: to be approved as an Adoptive or Foster parent, you must authorize a search of police records to verify that you
have no record which would make you unsuitable to be adoptive/foster parents. You may be approved if the social worker
feels that you have made a satisfactory adjustment since the arrest(s) or convictions.

For persons convicted of crimes against children such as neglect, abuse or sexual exploitation, the application shall be
denied.

TEN REFERENCES

Please provide names of ten (10) persons who know you both. Preferred references are persons living in the same community as applicants.

Name	Mailing address	Telephone

Name ____________________________________________

Your Family Background

Please tell us about the people who raised you. Who were they and did you get along with them?

How did you get along with your brothers and sisters when you were growing up?

Which of your family members are you still close to? How often do you see or speak with them?

Has any member of your family ever been arrested or changed with a violation of the law? No ( ) Yes ( )
if yes, please explain:

Has any member of your family and/or household ever been in foster care? No ( ) Yes ( )
if yes, please explain:

Your Childhood

As you were growing up, which family members were you closest to? Why?
What made them special to you?

What was the hardest part of growing up for you?

What was the best part of growing up for you?

What were you usually punished for?

How were you punished? By Whom?

Your Education

How did you feel about school?

What do you remember the most about school?

Your Marriage/Relationship

List three things you like most about your present marriage relationship?

What do you most admire about your spouse/partner?

What crisis have you dealt with together and how was it handled?

What would make your marriage/relationship better?

Previous Marriages

If this (these) marriages(s) ended in divorce, what was the reason for the divorce(s)?

Have you ever been married before? No ( ) Yes ( ) If yes, how many times?

Dates of previous marriages:

Marriage ended in : Divorce ( ) Death ( ) Date this occurred:

If this (these) marriages(s) ended in divorce, what was the reason for the divorce(s)?

How is your present marriage/relationship different?

Do you have children from other than your current marriage/relationship? Yes ( ) No ( )

Name of child

Birth date

Where do they live know?

If these children are not living with you, in what ways do you keep in touch and provide support?

For Single Applicant

Please describe your dating patterns for the last six (6) months:

What role will this person have with children placed with you?

How old were you when you had your first child?

What three (3) things do you like most about being a parent?

What is special about each of your children?

What do your children do that upsets you the most?

What do you do when you are upset with your children?

How do you discipline your children? What methods are most effective?

What advice would you give to a person thinking about having their first child?

Your Role as an Foster/Adoptive Parent

Why do you want to foster/adopt a child?

What do you think will be the best part about being a foster/adoptive parent?

What do you think will be the hardest part about being a foster/adoptive parent?

Please tell us about the people who will help you out when you need child care, advice, etc?

How will the placement of a child affect your relationship to other immediate and extended family members?

How would you handle visits between the children and their parents?

If you are now ( or have ever ) parented a child that was not your birth child, what was the relationship ( for example, step child, relative, friend ) and how long did you parent this child?

In what ways was it different?

Are you willing to accept a child with the following?

NO	YES		MILD	MODERATE	SEVERE
		Emotional Problems
		Sexual Acting Out
		Behavioral Problems
		Physical Handicaps

For Specific Placements

How often have you seen this child during the past year?

Have you ever provided care for this child?

Have you been aware of problems between this child and their parents? If so, please explain:

Medical History

Are you currently under the care of any doctor? Explain:

What medications do you use regularly? Explain:

Do you have any chronic or recurring physical ailments ( such as migraine, backaches, arthritis )? Explain:

Please list any injuries, illnesses or operations you have had as an adult which required hospitalization?

MEDICAL HISTORY

Are you currently under the care of any doctor? Explain:

What medications do you use regularly? Explain:

Do you have any chronic or recurring physical ailments ( such as migraine, backaches, arthritis)? Explain:

Please list any injuries, illnesses or operations you have had as an adult which required hospitalization?

To be Completed by Both Applicants

Has any member of your household ever had a drug or alcohol related problem? Yes ( ) No ( )
If yes, please explain:

Name any close friends or relatives who are foster parents.

How does each member of your family show love and affection?

When someone in the family is sad or upset, what do the other family members do to help?

In what ways has your relationship as a couple changed since becoming parents?

When your family has to make a decision, who participates and how do you arrive at a decision?

How do you resolve or settle disagreements?

What usually makes each members of your family angry?

How does each of your family members act when they are angry?

Applicant #1:

Applicant #2

Children

Who is responsible for housekeeping chores in your family?

What adjustments would you have to make if a child coming into your home has a religious preference other than yours?

What kinds of recreational activities does your family participate in?

In which, if any, community activities are members of your family involved? (For example, schools, volunteer groups, neighborhood association, scouts, etc.)

ACKNOWLEDGMENT AND SIGNATURE: In signing this form, foster/adoptive parents are
verifying that they have received a copy of and are acknowledging the following conditions of
licensure/approval and that the information provided on this application is a truthful representation.

The persons given as references will be contacted by mail, telephone or in a home visit.
Police reports and FBI fingerprints will be checked and verified.
Military history, employment, marriage and divorces will be verified.
Medical records of the applicants will be requested and reviewed.
Pre-service training is mandatory for both applicants (and those household members over age 18)
Foster parents agree to adhere to the laws and regulations applying to foster children.
New Mexico Children, Youth and Families Protective Services Division, has the right and the duty to visit the foster home and to visit the adoptive children in the
adoptive home prior to the finalization of the adoption.
A foster child shall not be surrendered to the care and control of any person or relative of the child, other that a social worker with Now Mexico Children, Youth and Families
Department, Protective Services Division, without authorization from PSD.
If a low officer takes protective custody of any foster child (under Section 32A-4-6 of the Children’s Code) foster parents shall surrender custody of the foster child to the law
officer.
No independent planning, including adoption planning, for foster children shall be made by the applicant(s).
An application for foster care/adoption does NOT guarantee a license. Approval for placement of a child. An approval or denial is based on the suitability of the family for children for
whom the Children, Youth and Families Department has responsibility.
I (WE0 UNDERSTANT THAT SIGNING THIS APPLICATION DOES NOT GUARANTEE THAT A FOSTER HOME LICENSE WILL BE ISSUED TO ME (US). THIS
APPLICATION IS THE BEGINNING STEP IN COMPLETION THE HOME STUDY PROCESS.
If my (our) application is approved, I (we) am (are) NOT guaranteed placement in my (our) home.

_________________________________
First Applicant Signature Date

_________________________________
Second Applicant Signature Date