Caregiver Application

CAREGIVER APPLICATION UNITY #_________________ Division of Child & Family Services (DCFS) Clark County Department of Family Services (DFS) Washoe County Department of Social Services (WCDSS) Be sure that this application is completed in full and all required "separate sheet" attachments have been provided. Application for (check all that apply): Foster Care ICPC Adoption Relative/Specific Name:____________________________ Contractor Radio (Name of contract agency)____________________________________________ How did you learn about the program: Applicant #1 Name (First) T.V. Newspaper Friend Relative Agency/Court Foster Parent Other _____________________________________________________________________________________________ _________________________ (Middle)___________________ (Last) ____________________________________ Date of birth Place of birth: City, ________________ State, ________ Country, _____________ _______________________________________________________________________ Social Security #______________________ Driver's Lic. #_______________________State_____________ RACE/ETHNICITY: Cauc. African American Tribe Asian/Pacific Isl. Hispanic Other Identify)_________________________ / Member Number: ______________________ Native American/Alaskan Native __________________ Tribal Are you a US Citizen? Yes No Legal Resident? Yes No If "Yes", Resident number ____________________ What languages do you speak? ____________________________________________ Occupation___________________________ Employer ______________________________Address___________________________________________________ Work phone______________________ How long at current job (If less than five years, please list employment history for past five years by attaching a separate sheet) Do you have health insurance? Yes No If yes, Agency _________________________________________________ Would your health insurance cover an adopted child? Yes No Applicant #2 Name (First)____________________ (Middle) _________________ (Last) ___________________________________ Date of birth Place of birth: City, _________________ State, ________ Country, ____________ Social Security #______________________ Driver's Lic. #_______________________ State____________ RACE/ETHNICITY: Cauc. African American Tribe Asian/Pacific Isl. Hispanic Other (Identify)_________________________ / Member Number:_________________ Native American/Alaskan Native _____________________ Tribal Are you a US Citizen? Yes No Legal Resident? Yes No If "Yes", Resident number _______________________ What languages do you speak? __________________________________ Occupation _________________________ Employer _____________________________ Address___________________________________________________ Work phone______________________ How long at current job (If less than five years, please list employment history for past five years by attaching a separate sheet) Do you have health insurance? Yes No If yes, Agency ______________________________________________ Would your health insurance cover an adopted child? Yes No Residence: House Apartment Condo Mobile Home if mobile home, year built____________ Do you own your home or rent? Own Rent Other (specify) ___________________________________ Total square feet in residence How long at this residence?_______________________ Residence address _____________________________________________City _________________State__________ County ______________________ Residence phone ( ) Zip_____________ Mailing address (If different)____________________________________________City ________________ State__________ Please provide detailed directions to your residence Email _________________________________________ Zip______________ Cell phone ( )_____________________________ (Applicant #1) Cell phone ( )_________________________ (Applicant #2) 1 Revised 3/06 American LegalNet, Inc. www.FormsWorkFlow.com CAREGIVER APPLICATION Check if for 1 Address FROM UNITY #_________________ List previous addresses for the past 10 years (Include City, State & Zip ­ use separate sheet if needed) Applicant TO 5 Address FROM TO Check if for Applicant 1 2 1 2 1 2 1 2 2 FROM 1 TO 6 2 2 2 2 FROM TO 1 1 1 3 FROM TO 7 FROM TO 4 FROM TO 8 FROM TO List ALL household members (In "Relationship to applicant" space list son, daughter, stepson etc.) Name 1 2 3 4 5 Social security # Birth date Relationship to Applicant #1 #2 6 7 8 9 10 Name Social security # Birth date Relationship to Applicant #1 #2 List extended family for Applicant #1 not living in the home (Include children, parents, brothers and sisters) Name of extended family 1 2 3 4 5 6 7 Age Relationship Occupation Address Phone with area code List extended family for Applicant #2 not living in the home (Include children, parents, brothers and sisters) Name of extended family 1 2 3 4 5 6 7 Age Relationship Occupation Address Phone with area code List household's average monthly income ( list all sources of income & attach documentation of this income) Gross monthly $ $ $ $ $ $ $ $ Savings $ Real Estate $ Annuity Type Type Applicant #1 Net monthly Source $ $ $ $ Gross monthly $ $ $ $ Applicant #2 Net monthly Source Assets Checking $ Stocks/bonds Trust Other Other Checking $ Stocks/bonds Trust Other Savings $ $ $ Real Estate $ $ $ $ $ $ Annuity $ Type $ Total combined monthly household income $ 2 Revised 3/06 American LegalNet, Inc. www.FormsWorkFlow.com CAREGIVER APPLICATION UNITY #_________________ Has Either applicant declared bankruptcy? Applicant #1 Yes No Applicant #2 Yes No Location where order was filed________________________________________ Date__________________________ (Attach bankruptcy disposition court order) Household expenses: Enter your household's average monthly expenses (Do not include expenses that are deducted from paychecks) House/Rent payments Utilities Telephone Gasoline / Auto maintenance Automobile payments Automobile insurance Groceries & household supplies $ $ $ $ $ $ $ $ Credit card payments Child support payments Loans outstanding Payments for other real estate Recreation & entertainment Life insurance Medical & dental insurance Medical care (not covered by insurance) Dental care (not covered by insurance) $ $ $ $ $ $ $ $ Child care Clothing Other $ $ $ Total Monthly Expenses $ 1. Have you ever applied to provide foster care? Applicant #1 Yes No Applicant #2 Yes No Name of agency you applied with: ______________________________________________________ Date __________________________ Ad