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 mental retardation? If yes, with which agency?

How did you hear about us?

Phonebook

Radio Station

TV Station

Other Agency

Newspaper Ad:

Current Provider:

Other

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: