Foster Parent Inquiry Form

Applicant Information

Name*

First Last

Gender*

Date of Birth*

Email*

Cell Phone*

Home Phone

Best time to call*

Please Specify*

Address*

Street Address Apt # City State ZIP Code

Do you have a co-applicant?*

Yes
No

Co-Applicant Name*

Relationship to Applicant*

Cell Phone*

Home Phone

Email

How did you hear about JCCA

(Please check all that apply)

JCCA Employee
Recruitment Event
Current Foster Parent
Previous Foster Parent
Other

Please Specify*

Home Information

What is the primary language spoken in your home?*

English
Spanish
Creole
Other

Please Specify*

Are there additional languages spoken in your home?*

Yes
No

Please Specify*

Have you been a foster parent previously?*

Yes
No

If yes, what agency?*

How many adults (18+) live in your home?*

How many children live in your home?*

How many bedrooms do you have?*

Do you have any pets?*

Yes
No

If yes, what kind of pet do you have?*

What type of home do you reside in?*

(Please select one)

Private House
Apartment

What type of apartment do you reside in?*

(Please select one)

1 or more bedrooms
Studio apartment
Railroad apartment (series of rooms connecting to each other in a line)

Preferences

JCCA offers several types of foster home programs. To help us find the right fit for you, please choose from the options below.

Are you interested in caring for young people with additional needs?

(Please check all that apply)

Youth with moderate to severe emotional & behavioral concerns
Mother/child pairs
Sibling groups
Children with serious medical conditions
Teens
Unaccompanied minors

Preferred Age Range of Foster Child:

(Please check all that apply)

0 - 5
5 - 12
12 and up
Any Age

Preferred Gender:

(Please check all that apply)

Male
Female
Any Gender

Please add any comments or questions for JCCA's Homefinding Staff:

Foster Home Services

Our Programs

Foster Parent Inquiry Form

Applicant Information

Home Information

Preferences

Our Programs