MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION FOSTER/ADOPT HOME ASSESSMENT APPLICATION
PRIMARY INTEREST FOSTERING ADOPTING
Please complete all spaces accurately and completely. Application does not place you under any obligation to Children's Division.
I. APPLICANT(S)
APPLICANT 1	APPLICANT 2
Name Last, First, M.I., Maiden	Name Last, First, M.I., Maiden
Birth Date	Birthplace	Birth Date	Birthplace
Sex	Race	Church Affiliation	Sex	Race	Church Affiliation
Last School Grade Attended	College Degree/Major	Last School Grade Attended	College Degree/Major
Name/Place of Last School	Name/Place of Last School
Occupation	Date Employed (Present Job)	Occupation	Date Employed (Present Job)
Working Hours	Work Telephone	Working Hours	Work Telephone
Military Service Yes No	Rank	Military Service Yes No	Rank
Type of Discharge	Date	Type of Discharge	Date
Have you ever been employed by the Children’s Division?	Have you ever been employed by the Children’s Division?
Yes No	Date Employed to	Yes No	Date Employed to
II. HOUSEHOLD COMPOSITION
Complete for everyone living in the home unless listed above. Attach additional pages, if necessary.
Name	Birth Date	Relationship	School/Employer	Grade/Time Employed
Complete for all children not living in the home. Attach additional pages if necessary.
Name	Birth Date	Relationship	Address	Phone
III. ADDRESS
County of Residence	Home Telephone Number
Email Address:
Home Address (Street, City, State, Zip Code)
Type of Home: Single Family Multi-Family Apartment Number of Bedrooms Number of Rooms
Directions to your home
IV. REFERENCES
List 3 (three) unrelated people who know you well.
Name	Address	City , State	Zip Code	Phone
V. SUPPLEMENTAL INFORMATION
Give name of adoptive child(ren), date and location of adoption(s) completed
Name	Date	City, State, Zip
Have you previously applied to this agency? YES NO
Result of application
Name other agencies to which you have applied to foster or adopt.
Result of application(s)
Have you had Foster or Adoptive placements through this or another agency? YES NO
Name of agency through whom you provide foster care or adopted.
Have you previously been studied in regard to a child custody (divorce) matter? YES NO
If yes, where and for whom?
Why do you wish to foster or adopt a child?
Child(ren) desired: Age Range Sex Number
Would you be willing to accept a child of a race/ethnicity/culture other than your own? YES NO
Would you be willing to accept teenaged children and sibling groups? YES NO
Would you be willing to accept a child from a different religious background than your own and allow that child to practice his/her own religious beliefs? YES NO
What are your family’s religious practices?
Would you be willing to participate in the development and implementation of a treatment plan designed to provide permanency for a child? YES NO
Are you willing to participate in training sessions designed to increase your knowledge about foster/adoptive children? YES NO
Are you willing to work closely with the parents of a foster child toward reunification? YES NO
DO YOU UNDERSTAND THE FOLLOWING: If yes, place “y” in the box provided, if no, place “n”. If you need more information about this topic, place an “m” in the box.
The difference between foster care and adoption?
That a foster child’s history is confidential?
That foster parents are responsible for the day-to-day care of foster children?
That foster parents are expected to be participating members of the family support team?
That foster parents are expected to work with birth families on reunification of children?
That foster care does not automatically lead to adoption?
That licensing as a foster home does not guarantee placement of a child?
That approval as an adoptive home does not guarantee placement of a child?
VI. MARITAL STATUS AND HISTORY
Marital Status: Single Separated Married Divorced Widowed Co-Habitating
Former Marriage(S), If Applicable (Attach Additional Pages If Necessary)
Applicant 1 Single Separated Married Divorced Widowed Co-Habitating	Applicant 2 Single Separated Married Divorced Widowed Co-Habitating
Former Spouse’s Name	Former Spouse’s Name
Date of Marriage	Date of Divorce	Date of Death	Date of Marriage	Date of Divorce	Date of Death
Present Marriage, If Applicable
Date of Marriage	Place of Marriage
Have there been any separations during this marriage? YES NO If yes, when & how long?
List every state each household member 17 years of age and older has lived in the past 5 years
Applicant 1
Applicant 2
Other Household Members
VII. FINANCIAL INFORMATION
A. Total Monthly Income	B. Total Average Monthly Expenses
VIII. LEGAL HISTORY
Has anyone living in your home ever been arrested and convicted of any law violation, other than minor traffic offenses?
If, so please give history of arrests, convictions, civil judgments and pending civil actions for all household members age 17 and older or any person under the age of 17 who has been certified as an adult.
IX. CHILD ABUSE AND NEGLECT HISTORY
Please list the involvement of any household member, age 17 or older, with the children’s division or other child protection agency: (list the type of agency, where and why the household member was involved with the agency)
X. HEALTH
Describe the present health of all household members (please include medications, handicaps, medical conditions and mental disorders):
I understand that the completion/ submission of this application does not guarantee acceptance into the foster/adopt program. I understand that my signature on this application gives the children’s division the right to contact any individual or agency who may have information regarding my suitability for foster/relative/kinship/adoptive parenting. I also authorize the children’s division to complete child abuse and neglect and criminal background checks for the purpose of determining suitability for foster/relative/kinship/adoptive parenting. My signature also certifies that information that I provide to the division is accurate and true to the best of my knowledge. I further understand that the foster parent licensure application process and subsequent related activity is a public record and will be made available to the public upon request. I further understand that some information from this application and subsequent related activity may be shared with parents and other parties involved in the placement decisions for children in division custody. Some of the information contained in this application cannot be released without my written permission or a court order.
Applicant Signature ►	Social Security Number	Date Signed
Applicant Signature ►	Social Security Number	Date Signed
Please attach a photograph (if you have one) of all family members standing in front of your home.
THANK YOU FOR YOUR APPLICATION AND YOUR INTEREST IN OUR PROGRAMS.