Form Lic 01a - Resource Family Application Page 3
Download a blank fillable Form Lic 01a - Resource Family Application in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Lic 01a - Resource Family Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
VII. CHILD DESIRED
I
I
Has a child been identified?
Check one:
Yes
No
If yes, complete LIC 01C.
G
I
I
Is the child currently in your home?
Check one:
Yes
No
G
IF A CHILD HAS NOT BEEN IDENTIFIED, PLEASE INDICATE YOUR PREFERENCES:
AGE(S)
I
I
I
I
I
I
I
0 TO 3 yrs
4 TO 8 yrs
9 TO 12 yrs
13 TO 15 yrs
16 TO 18 yrs
18 TO 21 yrs
No preference
SIBLING (GROUP OF)
I
I
I
I
I
0
2
3
4
5 or more
VIII. FOSTER CARE/ADOPTION/ LICENSURE HISTORY
Have you been previously licensed, certified, or approved to provide foster care?
G
If yes, name of agency(s): _______________________________________________________________________
Type of license/certification/approval: ______________________________________________________________
Have you previously applied for adoption?
G
If yes, name of agency(s): _______________________________________________________________________
Have you previously been licensed to operate a non-foster care community care facility, child care center, family child care
G
home, or residential care facility for the elderly or chronically ill?
If yes, type of license: __________________________________________________________________________
Have you previously been employed by or volunteered at a community care facility, child care center, family child
G
care home, or residential care facility for the elderly or chronically ill?
If yes, name the facility(s): _______________________________________________________________________
Have you had a previous license, certification, relative or nonrelative extended family member approval, or resource family
G
approval application denial?
I
I
Check one:
Yes
No
If yes, name of agency(s): _______________________________________________________________________
Have you had a license, certification, or approval suspended, revoked, or rescinded?
G
I
I
Check one:
Yes
No
If yes, name of agency(s): _______________________________________________________________________
Have you been subject to an exclusion order?
G
I
I
Check one:
Yes
No
LIC 01A (2/17) (Mandatory)
RESOURCE FAMILY APPLICATION
PAGE 3 OF 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal