Resource Family Application - California Department Of Social Services Page 3
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4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RESOURCE FAMILY APPROVAL
FOSTER CARE/ADOPTION HISTORY
Have you previously applied for adoption?
G
If yes, name of Agency(s): _______________________________________________________________________
Have you been previously licensed, certified, or approved for foster care?
G
If yes, name of Agency(s): _______________________________________________________________________
______________________________________________________________
What type of license did you obtain? _
G
Have you previously been employed by or volunteered at a community care facility? If yes, name of facility(s) :___________
G
____________________________________________________________________________________________________
Have you had a previous license, certification, relative or nonrelative extended family member application denial, license
G
suspension or revocation, or been subject to an exclusion order?
I
I
Check one:
Yes
No
VII. CHILD DESIRED
I
I
Has a child been identified?
Check one:
Yes
No
G
I
I
Is the child currently in your home?
Check one:
Yes
No
G
EDUCATION
DATE OF PLACEMENT OR
RELATIONSHIP
(GRADE, NAME &
SEX
FUTURE DATE TO BE PLACED
TO APPLICANT(S)
ADDRESS OF SCHOOL)
: IF THE CHILD HAS NOT BEEN IDENTIFIED, PLEASE INDICATE YOUR PREFERENCES
SIBLING
AGE(S)
SEX
ETHNICITY
(GROUP OF)
I
I
I
I
2
History of physical abuse and/or
0 TO 3 yrs
Male Only
neglect
I
4 TO 8 yrs
I
Female Only
I
I
History of sexual abuse
I
3
9 TO 12 yrs
I
History of mental illness
I
13 TO 15 yrs
I
No Preference
I
I
Medically Fragile
4
I
16 TO 18 yrs
I
Physically Disabled
I
18 TO 21 yrs
I
I
Intellectually Challenged
5 or more
I
No preference
I
Learning Disability
I
I
Alcohol/Drug Exposure
N/A
I
Oppositional/Defiant Behavior
I
Adverse Parental Background
I
Different Religious Faith
I
Different Ethnic and/or Cultural
Background
I
Non-Ambulatory
RFA-01(A) (11/14)
RESOURCE FAMILY APPLICATION
PAGE 3 OF 4
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