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Resource Family Application form (1)

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

"*" indicates required fields

Family Status

Current family status:*

Date of marriage*

Has your family status been consistent for two years (prior to applying with COBYS)

Note: Family status must be consistent for two years prior to applying to become a resource parent with COBYS. Please reach out to your resource home specialist or email careforkids@cobys.org, and do not proceed with this application if your family status has changed in the last two years.

Applicant 1

Name*

First Middle Last

Preferred Name

Alias/Former/Maiden Name

Date of Birth*

Applicant 2

Name*

First Middle Last

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.

Address

Physical Address*

Street Address City State ZIP Code

County*

School District*

Number of years at this address*

Is Mailing Address the same as Physical Address?*

Mailing Address (when different from Physical Address)*

Street Address City State ZIP Code

Have you lived outside of Pennsylvania within the last five years?*

How many addresses (different from your current address) have you had in the past ten years?*

List all of your previous addresses from the past ten years: address, county, dates of residence and who resided at that address.

Address 1 (include county)

Dates

Who?

Address 2 (include county)

Dates

Who?

Address 3 (include county)

Dates

Who?

Address 4 (include county)

Dates

Who?

Address 5 (include county)

Dates

Who?

Address 6 (include county)

Dates

Who?

Address 7 (include county)

Dates

Who?

Primary/Preferred Contact for COBYS communications*

Phone #*

Applicant 1 - Contact Information and Background

Email Address*

Social Security #*

Cell #*

Work Phone #

Home/landline #

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)*

If not legally married, 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*

Applicant 2 – Contact Information and Background

Email Address*

Social Security #*

Cell Phone #*

Work Phone #

Gender*

Are you a member of an American Indian tribe?*

Racial Identity*

Ethnic Identity*

Other Racial Identity*

Language

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.*

Applicant 1 – Employment

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.*

Applicant 2 – Employment

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.*

Applicant 1 – Education

High School Name*

Grade Completed*

Graduation Date

Have you attended vocational school/training?*

List all training certificates you received, name of the school(s) attended, and year of completion.

Have you attended college or university?*

No. of yrs. attended*

College/university name(s)*

List all degrees earned

Major(s)*

Graduation Date(s)

Applicant 2 – Education

High School Name*

Grade Completed*

Graduation Date

Have you attended vocational school/training?

List all training certificates you received, name of the school(s) attended, and year of completion.*

Have you attended college or university?

No. of yrs. attended*

College/university name(s)*

List all degrees earned

Major(s)*

Graduation Date(s)

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(countries) 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?*

Applicant 1 – Legal Information

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.

Applicant 2 – Legal Information

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.).*

What pre-service training would you prefer to attend?*

Please list any special accommodations you will need during the approval process and training (accessible parking and training space, learning or literacy needs, etc.)

Acknowledgements and Signatures

Prior to submitting this application, please review the COBYS Family Services Notice of Privacy Practices posted on the COBYS website.

Type your name(s) to signify your acknowledgement to the terms and to submit the form.*

Date*

Test Page

Resource Family Application form (1)

Family Status

Applicant 1

Applicant 2

Address

Applicant 1 - Contact Information and Background

Applicant 2 – Contact Information and Background

Applicant 1 – Employment

Applicant 2 – Employment

Applicant 1 – Education

Applicant 2 – Education

Household Members

Interest in Foster Care/Adoption

Applicant 1 – Legal Information

Applicant 2 – Legal Information

Previous Agency Affiliations

Acknowledgements and Signatures

The Counseling Center

COBYS Permanency Unit