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1 CHILD FOSTER CARE APPLICANT AUTOBIOGRAPHY **PLEASE NOTE THE AREAS TO BE COMPLETED INDIVIDUALLY WHILE OTHER AREAS MUST BE COMPLTED JOINTLY BY BOTH APPLICANTS** Identifying Information of Applicant #1 Your Full Name: What name do you prefer to be called: Date of Birth: Place of Birth: Address: City: State: Zip: Home Telephone Cell Your Work Email address: Social Security Number: Your Race: Religious Affiliation or church you attend: Emergency contact: Relationship: Telephone Family History of Applicant #1 Your Mother’s Name: Age: Your Father’s Name: Age: Where do your parents reside? Describe your parents’ overall health. If a parent is not living, please describe when they died and the cause of their death. Please describe your past and present relationships with your parents. What is your current level of contact with them? Please describe your parents’ relationship. How did they handle conflict and disagreements? ---PAGE BREAK--- 2 Do you have a step-parent? Please describe this relationship. Please describe how your parents encouraged you. How did your parents express their love/affection for you? Please list your siblings’ name, age, residence, occupation, marital status, and number of children. Name Age Town they reside Occupation Marital Status # of children Please describe your past and current relationships with your brothers and sisters. Do you have frequent contacts with them such as telephone calls, visits, holiday gatherings, etc.? Please describe the town(s) you lived in as a child. Did your family move frequently? What did your family do for fun when growing up? Describe some of your early childhood memories (such as family outings, vacations, rituals, traditions, celebrations, church, relatives, friends, neighbors, community event, etc.)? ---PAGE BREAK--- 3 What chores or responsibilities did you have when growing up? What methods of discipline or punishment were you exposed to as a child? What method was most effective? Least effective? What things did you do or your parent(s) help you to do to achieve independence? What, if anything, would you do differently than your parents? What important lessons or values did you learn from your parents? Educational Background of Applicant #1 Please describe schools you attended including grade school through higher education, location/town of school and years attended. Did you graduate from each school? Name of School attended: Location/town: Years attended: Year Graduated Describe your educational experiences: (Examples: Likes/dislikes, activities you participated in, challenges and successes, etc.) What was your major area of study in higher education, technical college, or university? ---PAGE BREAK--- 4 Occupational and Work Background of Applicant #1 Please describe your employment history. Begin with the most recent first. Name of Employer: Town: Position: Dates of Employment: Describe your current work including job responsibilities and work hours. What do you like the most and like the least about your current job? Have you ever been in the military? If so, what branch of service? Years served? Type of discharge? Date of discharge? Personal Information of Applicant #1 What do you do in your leisure time? What are your hobbies, talents, and interests? Describe any volunteer work, clubs, or organizations you are involved in. What do you consider significant events or greatest accomplishments in your life thus far? Discuss goals for the future such as educational, career, hobbies and/or relationships. ---PAGE BREAK--- 5 Please briefly describe your health history including; hospitalizations, current medications, significant health problems, mental health issues and/or ongoing health issues. Please describe your current use of alcohol or tobacco. Do you have a history of chemical abuse/dependency? Have you ever been to treatment? Length of abstinence. Please describe. How do you show affection to children? Personal Characteristics of Applicant #1 Describe yourself (physical description, personality, temper, sense of humor, etc.). Describe your personal What are your weak or vulnerable spots? Describe your spouse/significant other’s personality, and weaknesses. Describe your ability to acknowledge and appreciate individual differences among people without being judgmental? Coping Skills and History of Stress Management of Applicant #1 Please describe the worst thing you have ever had to deal with. What did you do and how did it effect you? ---PAGE BREAK--- 6 Please describe any significant losses or stressors you have experienced (deaths, moves, illnesses, problems at work, relationship problems, financial difficulties, divorces, etc.). Why was it so hard and what helped you to recover? Please describe how you express happiness. Please describe how you express affection. Please describe how you express sadness and loneliness. Please describe how you express anger and frustration. How do you know when you are getting stressed out? How do you handle being stressed out? What pushes your buttons? In what ways could a child with emotional or behavioral problems push your buttons? Have you really wanted something you could not have? What was it? How did it feel? How did you react or did you ever give up? Do you ever feel unappreciated by your family or on the job? Under what circumstances? How did you handle it? Have you ever felt or been rejected by someone you loved, particularly your children? What was it like? How did you handle it? ---PAGE BREAK--- 7 What is your biggest source of support when you are upset or need help? What outlets do you have to relieve stress (physical exercise, hobbies, support groups, therapists, use of chemicals, etc.)? Describe your flexibility with day to day events. Are you able to go with the flow or do you have to have a set schedule or plan? Do you usually have a backup plan? Are you open to new ideas? Do you accept help if a situation becomes difficult to manage? Identifying Information of Applicant #2 Your Full Name: What name do you prefer to be called: Date of Birth: Place of Birth: Address: City: State: Zip: Home Telephone Cell#: Your Work Email address: Social Security Number: Your Race: Religious Affiliation or church you attend: Emergency contact: Relationship: Telephone Family History of Applicant #2 Your Mother’s Name: Age: Your Father’s Name: Age: Where do your parents reside: Describe your parents’ overall health. If a parent is not living, please describe when they died and the cause of their death. Please describe your past and present relationships with your parents. What is your current level of contact with them? ---PAGE BREAK--- 8 Please describe your parents’ relationship. How did they handle conflict and disagreements? Do you have a step-parent? Please describe this relationship. Please describe how your parents encouraged you. How did your parents express their love/affection for you? Please list your siblings’ name, age, residence, occupation, marital status, and number of children. Name Age Town they reside Occupation Marital Status # of children Please describe your past and current relationships with your brothers and sisters. Do you have frequent contacts with them such as telephone calls, visits, holiday gatherings, etc.? Please describe the town(s) you lived in as a child. Did your family move frequently? What did your family do for fun when growing up? ---PAGE BREAK--- 9 Describe some of your early childhood memories (such as family outings, vacations, rituals, traditions, celebrations, church, relatives, friends, neighbors, community events, etc.). What chores or responsibilities did you have when growing up? What methods of discipline or punishment were you exposed to as a child? What method was most effective? Least effective? What things did you do or your parent(s) help you to do to achieve independence? What, if anything, would you do differently than your parents? What important lessons or values did you learn from your parents? Educational Background of Applicant #2 Please describe schools you attended including grade school through higher education, location/town of school and years attended. Did you graduate from each school? Name of School attended: Location/town: Years attended: Year Describe your educational experiences: (Examples: Likes/Dislikes, activities you participated in, challenges and successes, etc.) ---PAGE BREAK--- 10 What was your major area of study in higher education, technical college, or university? Occupational and Work Background of Applicant #2 Please describe your employment history. Begin with the most recent first. Name of Employer: Town: Position: Dates of Describe your current work including job responsibilities and work hours. What do you like the most and like the least about your current job? Have you ever been in the military? If so, what branch of service? Years served? Type of discharge? Date of discharge? Personal Information of Applicant #2 What do you do in your leisure time? What are your hobbies, talents, and interests? Describe any volunteer work, clubs, or organizations you are involved in. ---PAGE BREAK--- 11 What do you consider significant events or greatest accomplishments in your life thus far? Discuss goals for the future such as educational, career, hobbies and/or relationships. Please briefly describe your health history including; hospitalizations, current medications, significant health problems, mental health issues and/or ongoing health issues. Please describe your current use of alcohol or tobacco. Do you have a history of chemical abuse/dependency? Have you ever been to treatment? Length of abstinence. Please describe. How do you show affection to children? Personal Characteristics of Applicant #2 Describe yourself (physical description, personality, temper, sense of humor, etc.). Describe your personal What are your weak or vulnerable spots? Describe your spouse/significant other’s personality, and weaknesses. ---PAGE BREAK--- 12 Describe your ability to acknowledge and appreciate individual differences among people without being judgmental? Coping Skills and History of Stress Management of Applicant #2 Please describe the worst thing that you have ever had to deal with. What did you do and how did it effect you? Please describe any significant losses or stressors you have experienced (deaths, moves, illnesses, problems at work, relationship problems, financial difficulties, divorces, etc.). Why was it so hard and what helped you to recover? Please describe how you express happiness. Please describe how you express affection. Please describe how you express sadness and loneliness. Please describe how you express anger and frustration. How do you know when you are getting stressed out? How do you handle being stressed out? What pushes our buttons? In what ways could a child with emotional or behavioral problems push your buttons? ---PAGE BREAK--- 13 Have you really wanted something you could not have? What was it? How did it feel? How did you react or did you ever give up? Do you ever feel unappreciated by your family or on the job? Under what circumstances? How did you handle it? Have you ever felt or been rejected by someone you loved, particularly your children? What was it like? How did you handle it? What is your biggest source of support when you are upset or need help? What outlets do you have to relieve stress (physical exercise, hobbies, support groups, therapists, use of chemicals, etc.)? Describe your flexibility with day to day events. Are you able to go with the flow or do you have to have a set schedule or plan? Do you usually have a backup plan? Are you open to new ideas? Do you accept help if a situation becomes difficult to manage? Family Relationships and Issues of Applicant #1 & #2 ***Remainder of form to be completed by a single applicant also*** Describe your current marriage or significant relationship. When and how did you meet? If you are married, how long did you date and the length of your engagement period before marriage? ---PAGE BREAK--- 14 Describe the date and place of your marriage. What do you see as your as a couple? In what areas do you handle things as a team? Are there areas in which you strongly disagree? How do you manage or resolve conflicts or disagreements? Have you ever had problems in your relationship/marriage? Can you describe the problems? How did you deal with these problems? Have you ever considered divorce in your current marriage? Is yes, please explain: What activities do you enjoy as a couple? Please discuss fertility issues in your relationship. Have you experienced grief or loss issues related to fertility? How does this affect your relationship? Please describe any previous marriages/significant relationships including dates, any ongoing contact with ex-spouse/partner and were children involved? Discuss child support and visitation issues. Have you or anyone in your immediate or extended families had problems with drinking or drug usage? ---PAGE BREAK--- 15 Been involved with law enforcement due to alcohol or drugs? Please discuss how it was resolved and how it has affected you personally. Have you or anyone in your immediate or extended families been neglected? Been emotionally, physically, or sexually abused? Please discuss how it was resolved and how it has affected you personally? Have you or anyone in your immediate or extended families ever been reported, accused of, or investigated for abuse or neglect of an adult or child? If yes, please describe what happened. Have you or anyone in your immediate or extended families ever had parental rights terminated, voluntarily or involuntarily? If yes, please describe what happened. Describe how the topics of sexuality and sex education were handled by your parents. Describe how you plan to approach these topics with your own children, foster or adoptive children. Children in Home Child #1 Child #2 Child #3 Child #4 Child #5 Name Date of birth SSN Sex Race School Grade Adopted/Biological/ Step-child Date entered household If any child listed above is not a permanent member of your household, please note the child’s name and describe the circumstances. ---PAGE BREAK--- 16 Describe each child’s characteristics including physical description, personality, how they express their feelings, likes/dislikes, hobbies, interests, disabilities, current health status, educ ational situation including grade and school attended and overall functioning at home and school. Continue on back page if you need more space to write. Describe each parent’s relationship with each child. How do your children get along with each other? Have you presented the idea of foster care or adoption to your children? What did you tell them and how did they respond? Discuss each child’s attitude toward foster/adoptive plan and how such placements are likely to impact the child. List any adult children you have, ages, where they live and current level of contact or relationships with them. Describe your relationships with your adult children. ---PAGE BREAK--- 17 Non-Applicant Adults Living in the Home Please describe any other adults living in your household. Please include their name, age, date entered household, relationship to you the applicant, their education and health information. What will their role be with foster/adopt child(ren)? Support System of Both Applicants Describe your current support system including; family, friends, church, support group, and community. Describe your willingness to accept help, suggestions, or counseling from other people (such as social workers, school personnel, therapists, doctors). Describe friends and extended family’s (including parents and siblings) attitude toward your foster/adopt plan. How much will they be involved and how will these relationships change with the implementation of your foster/adopt plan? Who will provide child care or respite care (licensed provider is preferred)? In case of incapacity or fatality who will be responsible for the foster/adoptive child(ren)? ---PAGE BREAK--- 18 Parenting Skills of Both Applicants Describe your parenting style. Describe your parenting philosophy and values you strive to maintain. In your opinion, what is a parent’s biggest responsibility? Do you parent as a team with your partner or is there a primary caregiver in your family? Describe your parenting experience. How does parenting fit into your day to day life? Do you parent your children differently? Please describe. Describe your home environment (rigid or structured; flexible or chaotic, what are the household rules; what are the roles and responsibilities of household members, what are your daily routines; how do you involve the children in decision making, etc.)? What are the rules, the expectations and the responsibilities of children in your home around such things as; watching TV, playing video games, allowances, curfew, bedtimes, being with friends, going on dates, grades, extracurricular activities, dress code, using the telephone, listening to music, type of music allowed, going for walks, fighting, pets, outside activities, homework, lying, teasing, keeping secrets)? Describe how members of your family respect each other’s privacy? What are the bathroom, nudity, and bedroom privacy rules in your home? ---PAGE BREAK--- 19 Have you ever had full time responsibility for a child who had emotional or behavioral problems? Please describe this parenting experience. Describe how you normally discipline your children. How will you discipline other people’s children? What are your methods of discipline and consequences? (check all that apply) Withdrawal of affection Negotiations of expectations Withhold privileges Force Sending to bed early Yelling Withholding food Praise and demonstration of love Talking with child Threats Nagging Isolation/time outs Spanking Demonstration of hurt feelings Scolding Arguing with child Natural consequences Silence toward child Additional responsibilities Delay punishment Giving child options Grounding Rewarding good behavior Modeling positive behavior Giving or taking child’s allowance Swearing What do you do when you are angry with a child? What would you do if a child argues with you, has a temper tantrum, or misbehaves in public? How do you react to a child who expresses or experiences anger, age defiance, non-compliance, or withdrawal? What are your previous experiences working with social workers, therapists, special education professionals, courts, etc.? ---PAGE BREAK--- 20 What has been your experience with the school system? Do you feel equipped to advocate so the child will receive necessary services? Adoptive or Foster Parenting Discuss the type of care your family wishes to provide including; short term (respite or emergency care), foster care, foster care with the willingness to adopt or adoption. How did you decide to foster/adopt? Will this change your life/relationship? How have you prepared your family to provide this type of care? What do you hope your family will experience in caring for a foster or adoptive child? Why do you think parents maltreat their children? How do you think they feel? How do you think children feel about their abusive parents? How do you feel about parenting another person’s birth child? What are your expectations and feelings toward birth parents (positive or negative)? What are some ways you could connect, mentor, and work positively with the foster child’s birth parents, even if you don’t like how they’ve treated their children? ---PAGE BREAK--- 21 Would expectation or responsibilities of foster children be different from those of your children? What would you do if a foster/adoptive child swears? What would you do if a foster/adoptive child is caught smoking? What would you do if a foster/adoptive child came home drunk or high on drugs? How would you talk to children about sex, sexuality, intimacy, and sexual experimentation? How do you feel about a foster/adoptive child using birth control? What would you do if a foster/adoptive child was acting out sexually to you, your spouse, your children or to their friends? Permanency Planning and Attitudes and Beliefs Regarding Foster Care/Adoption Issues Describe your understanding of a foster/adoptive child’s experiences of separations, loss and attachment. What are your feelings about the impact of birth family history and how it relates to the child’s sense of identity (special traditions for holidays, child’s previous lifestyle and norms)? ---PAGE BREAK--- 22 How would you support a foster/adoptive child discussing memories of birth family, including fantasies the child may have about their birth family? What does your family plan to do to make a child (foster or adoptive) feel part of the family? Is your family able and committed to meet the long-term needs of children in care? Is there anything that a foster or adoptive child could do to make you want to give up? Is your family prepared to see a foster child transition back home or to a permanent family? What are your feelings about children participating in therapy, being on medications, receiving special education or other services? Are you willing to provide transportation to and from visits for a foster/adoptive child? Are you willing to allow visits to take place in your home? Cultural Awareness and Diversity Describe your experiences with people of other races or cultures. Describe whether or not diversity issues have caused conflict or problems in your life and how they were or were not resolved (race, poverty, religion, traditions, daily living standards, et ---PAGE BREAK--- 23 Have you ever been in a social situation when you have been the only one like yourself? Describe. Describe your family’s ability to care for a child of other races or cultures. Are there people of other races or cultures in your family? How will having a foster/adoptive child of a different race or culture affect other people in your home and in your extended family? Do you feel prepared to foster/adopt a child of a different race or cultural heritage? Describe ways you can help a foster/adoptive child stay connected to and learn about their racial or cultural heritage (toys, videos, books, games, customs, activities, adult role models, art museums, plays, concerts, music, meals, skin, and hair care). Would a child’s race make them a target of discrimination in your school, community, or extended family? If so, describe how you would plan to deal with child safety issues and the source of the discriminatory behavior. What in your current lifestyle would support a child’s ability to stay connected to their racial or cultural heritage? ---PAGE BREAK--- 24 Religious Affiliation and Spiritual Beliefs Describe the impact of religious or spiritual beliefs on your family’s day to day life. Do you attend church regularly or have family rituals based on your religious beliefs (what church activities, groups, were you baptized or confirmed, etc.)? Often times a child entering your home will have different religious beliefs. How do you see your family’s religious beliefs impacting a foster child? How do you plan to meet the child’s religious needs? Would you allow a foster child with a different religious background to practice their beliefs and attend a church of their own? Would you provide transportation? Family Finances Give a brief description of your financial stability. How will foster care impact your financial situation? Briefly list major debts including; mortgages, rent, utilities, car loans, credit cards, medical bills, insurance, child support obligations, other bank loans, etc. How are financial decisions made in your household? Who manages the money and pays the bills? ---PAGE BREAK--- 25 Does your employer have any policies regarding taking leave for appointments, meetings, illnesses, etc.? Does your employer have any benefits for adoptive parents? Residence and Physical Environment Please briefly describe your home and neighborhood. (Own/rent, urban/rural, number of bedrooms, size of home, color, back yard, playground equipment, handicap accessibility, etc. The simple kind of things helpful to describe to a child who may be placed in your home). Describe the schools in your community including; elementary, junior high school, and special education. How close are they to your home? Is transportation provided to school from your home? If not, are you willing to provide transportation? Describe accessibility to medical facilities in your area. Do you have an approved municipal water supply system? Do you have a valid driver’s license? Do you drive a car? Do you have car insurance? Please provide a copy of each applicant’s driver’s license and proof of insurance Do you have an approved child safety seats available? Will you obtain appropriate seats? ---PAGE BREAK--- 26 Please describe sleeping arrangements for foster children. A foster child must be provided with a separate suitably sized bed. They must have a sleeping space in the home that is not used for a second purpose, such as a family room. A foster child may share a bedroom with other children. A dining area in the home must be able to accommodate at one time all the persons living in the home. Does your family dining area meet this requirement with additional children? Signature of Applicant #1 Date Completed Signature of Applicant #2 Date Completed CCSS 8/2017