dfs : : Pre-App Foster Parent

Last Name

First Name

M.I.

Age

Street Address:

City:

Zip:

County:

Phone No:

School District:

Others in Household:	Relationship:	Age:

Employment/Income Information YOU:
You:
Occupation:
Employer:
Income if not employed:

Employment/Income Information YOUR SPOUSE:
You:
Occupation:
Employer:
Income if not employed:

Have you ever been a foster parent or provided Life Sharing to persons with Intellectual Disabilities? If yes, with which agency?

Would you like to have a staff person contact you with more information and/or to receive an application? No Yes
If yes, please indicate the best time for someone to call when you might have 15-20 minutes to receive further information. Best time: