Resource Family Application

COBYS > Resource Family Application

Resource Family Application form

COBYS Family Services application for prospective resource families who have attended an Information Session within the past year.

Step 1 of 2

Basic Information
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What pre-service training would you prefer to attend?*
Please select a Training Session
- Winter: January 14, 21, 28, February 4, 11, 2027 (6p-8p)
Please list any special accommodations you will need during the approval process and training (accessible parking and training space, learning or literacy needs, etc.)
Information
Current family status:*
Date of marriage*
Date(s) of divorce finalization*
Date of spouse's death*
Note: Family status must be consistent for one year prior to applying to become a resource parent with COBYS. Please reach out to your resource home specialist and do not proceed with this application if your family status has changed in the last year.
Applicant 1
Name*
First Middle Last
Preferred Name / Alias/Former/Maiden Name
Preferred Name Alias/Former/Maiden Name
Date of Birth*
Applicant 2 (if applicable)
Name
First Middle Last
Preferred Name / Alias/Former/Maiden Name
Preferred Name Alias/Former/Maiden Name
Date of Birth
Note: For the remainder of this form, please pay attention to who is Applicant 1 and Applicant 2.
Physical Address*
Street Address City State ZIP Code
Mailing Address (if different from Physical Address)
Street Address City State ZIP Code
County*
Township/Municipality*
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County*
County Township/Municipality
School District*
Home/land line phone
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Address
School District Home/land line phone
Primary/Preferred Contact for COBYS communication*
Phone*
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Primary/Preferred Phone Number for COBYS communication*
Additional Information – Applicant 1
Personal Cell Phone #*
Work Phone #*
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Contact Information*
Personal Cell # Work Phone #
Email Address*
Social Security #*
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Address*
Email Address Social Security #
Gender*
Are you a member of an American Indian tribe?*
Racial Identity*
Ethnic Identity*
Other Racial Identity*
Languages
Primary Language Other Languages Spoken
Religious Affiliation
Religious Affiliation Place of worship
Are you a citizen or legal permanent resident of the United States?*
Place of Birth (City, State, Country)*
Have you lived outside of Pennsylvania within the last five years?*
List all of your previous addresses from the past ten years. Include county and dates of residence.*
If single, are you currently in a significant relationship?
Does your significant other spend more than 30 nights of the year in your home?*
Your significant other’s name*
Additional Information – Applicant 2
Cell Phone #
Work Phone #
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Contact Information
Personal Cell # Work Phone #
Email Address
Social Security #*
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Address*
Email Address Social Security #
Gender
Are you a member of an American Indian tribe?
Racial Identity
Ethnic Identity
Other Racial Identity
Language
Primary Language Other Languages Spoken
Address
Religious Affiliation Place of worship
Are you a citizen or legal permanent resident of the United States?
Place of Birth (City, State, Country)
Have you lived outside of Pennsylvania within the last five years?
List all of your previous addresses from the past ten years. Include county and dates of residence.
Employment – Applicant 1
Occupation*
Are you currently employed?*
Current Position/Title*
Employer*
Employer Address*
Phone*
Mon-Fri work schedule*
Weekend work schedule*
Length of current employment*
Gross annual salary*
Are you in the military or military reserves?*
Please list previous employment and start/end dates for the past five years.*
Employment – Applicant 2
Occupation
Are you currently employed?
Current Position/Title
Employer
Employer Address
Phone
Mon-Fri work schedule
Weekend work schedule
Length of current employment
Gross annual salary
Are you in the military or military reserves?
Please list previous employment and start/end dates for the past five years.
Education – Applicant 1
High School Name*
Grade Completed*
Graduation Date
Have you attended vocational school/training?*
Please list all training certificates you received, name of the school(s) attended, and year of completion.
Have you attended college or university?*
Please list all degrees earned*
College/university name*
Major(s)*
Number of years attended*
Graduation Date
Education – Applicant 2
High School Name
Grade Completed
Graduation Date
Have you attended vocational school/training?
If yes, please list all training certificates you received, name of the school(s) attended, and year of completion.
Have you attended college or university?
Please list all degrees earned
College/university name
Major(s)
Number of years attended
Graduation Date
Household Members
How many children do you have through birth, adoption, or legal guardianship?*
Please provide the following information for each child.
Child 1*
Full Name Birthdate Age
Name*
Race/Ethnicity Relationship to you Grade/Employment
Child 2*
Full Name Birthdate Age
Name*
Race/Ethnicity Relationship to you Grade/Employment
Child 3*
Full Name Birthdate Age
Name*
Race/Ethnicity Relationship to you Grade/Employment
Child 4*
Full Name Birthdate Age
Name*
Race/Ethnicity Relationship to you Grade/Employment
Child 5*
Full Name Birthdate Age
Name*
Race/Ethnicity Relationship to you Grade/Employment
Child 6*
Full Name Birthdate Age
Name*
Race/Ethnicity Relationship to you Grade/Employment
Child 7*
Full Name Birthdate Age
Name*
Race/Ethnicity Relationship to you Grade/Employment
Child 8*
Full Name Birthdate Age
Name*
Race/Ethnicity Relationship to you Grade/Employment
Please list the names of any children above who do not live with you.
If any of your children are under the age of 18 and do not live with you full time, please note who they reside with. If there is a shared custody agreement, please provide details.
Are you hoping/planning to have birth children in the near future?*
Aside from you and your children, how many other people reside in your home?*
Please provide the following information for each additional household member.
Additional Household Member 1*
Full Name Birthdate Age
Name*
Race/Ethnicity Relationship to you Grade/Employment
Additional Household Member 2*
Full Name Birthdate Age
Name*
Race/Ethnicity Relationship to you Grade/Employment
Additional Household Member 3*
Full Name Birthdate Age
Name*
Race/Ethnicity Relationship to you Grade/Employment
Additional Household Member 4*
Full Name Birthdate Age
Name*
Race/Ethnicity Relationship to you Grade/Employment
Have any household members age 18+ lived out of state in the past five years?*
If yes, which household members and what state(s) and country did they reside in?*
Has your family composition changed in the last five years (birth, death, separation, divorce, etc.)?*
If yes, please provide details.*
Is there any additional information you would like to share regarding household members?*
Interest in Foster Care/Adoption
List the reasons why you are interested in providing foster care.*
Descriptions of the different types of foster care COBYS Resource Families provide.
Based on these descriptions, what type(s) of foster care are you open to considering? Please click all that apply.*
- Foster Care Only
- Foster Care and Adoption
- Adoption
- Short-Term Respite or Standby Care
What age range are you open to?*
Are you open to sibling groups?
How many siblings?*
What gender, race, and ethnicity of children you are open to? Please click all that apply.*
- Female
- Male
- American Indian
- Asian or Pacific Islander
- Black/African American
- White
- Hispanic
- Non-Hispanic
If you have limits regarding age, gender, race, or ethnicity, what are your reasons for this?*
Are you open to caring for children who speak languages other than English?*
Are you open to caring for children with medical needs?*
Are you open to caring for children with mental health needs?*
Are you open to caring for children with special education needs?*
Are you open to caring for children with behavioral challenges?*
Are you open to supporting children’s relationships with their birth family?*
Legal Information – Applicant 1
Do you have any past or pending civil or criminal charges?*
*Note: If yes, you will be required to provide details for each charge as part of the approval process.
Have you ever had a Protection from Abuse Order filed against you?*
*Note: If yes, you will be required to provide details regarding this situation as part of the approval process.
Legal Information – Applicant 2
Do you have any past or pending civil or criminal charges?
*Note: If yes, you will be required to provide details for each charge as part of the approval process.
Have you ever had a Protection from Abuse Order filed against you?
*Note: If yes, you will be required to provide details regarding this situation as part of the approval process.
Previous Agency Affiliations
How many foster/adoptive agencies have you been affiliated with in the past?*
Include agencies that you have applied to and whether or not you were approved. Provide the following information for each agency.
Agency #1 Name*
Dates of involvement*
Mailing Address*
Phone*
Contact Person*
Provide details regarding your affiliation with this agency (the reasons you closed or were not approved, if children were placed in your home, etc.).*
Agency #2 Name*
Dates of involvement*
Mailing Address*
Phone*
Contact Person*
Provide details regarding your affiliation with this agency (the reasons you closed or were not approved, if children were placed in your home, etc.).*
Agency #3 Name*
Dates of involvement*
Mailing Address*
Phone*
Contact Person*
Provide details regarding your affiliation with this agency (the reasons you closed or were not approved, if children were placed in your home, etc.).*
Agency #4 Name*
Dates of involvement*
Mailing Address*
Phone*
Contact Person*
Provide details regarding your affiliation with this agency (the reasons you closed or were not approved, if children were placed in your home, etc.).*

Acknowledgements and Signatures
Please read through the acknowledgements below before checking consent and dating this form. Please review the COBYS Family Services Notice of Privacy Practices posted on the COBYS website. Copy and paste this url: https://cobys.org/wp-content/uploads/2023/02/COBYS-npp_booklet_hc_provider.pdf You may also request a paper copy from COBYS staff.
Consent*
I swear/affirm that the information I/we have provided above is true and complete to the best of my/our ability. I understand that if I/we provide false information or fail to provide the above stated information, I/we may be denied approval as a resource parent or have my/our status as such revoked. I/We also acknowledge and agree that:
1. Application information is true and will be treated as confidential.

2. The applicant(s) is not obligated, if called upon, to perform the services herein applied for and that COBYS Family Services is not obligated to assign, or actively seek to assign the applicant a foster/adoptive child.

3. As part of the agency's approval process, additional personal information will be sought from the applicant(s) by COBYS personnel.

4. All prior foster care/adoption agencies will be contacted and asked to provide a reference.

5. By providing phone numbers and email addresses, the applicant(s) agree(s) to being contacted through these methods.

6. The applicant(s) has not been convicted of any offense related to the abuse of children or violent or assaultive behavior.

7. If applicable, the applicant(s) will submit a copy of protection from abuse order(s) after their application has been processed.

8. I, the applicant(s) have received, read, and understand COBYS Family Services Notice of Privacy Practices.
Date*
Terms*
- By submitting this form/clicking here and providing your phone number, you consent to receive informational text messages (e.g. class and event reminders, etc.) from COBYS Family Services at the number provided. Msg & data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP or clicking the unsubscribe link (where available). HELP for assistance. Privacy Policy & Terms www.coby.org/privacy-policy.

Resource Family Application

Resource Family Application form

Step 1 of 2

Basic Information

Information

Applicant 1

Applicant 2 (if applicable)

Additional Information – Applicant 1

Additional Information – Applicant 2

Employment – Applicant 1

Employment – Applicant 2

Education – Applicant 1

Education – Applicant 2

Household Members

Interest in Foster Care/Adoption

Legal Information – Applicant 1

Legal Information – Applicant 2

Previous Agency Affiliations

Acknowledgements and Signatures