Form Lic 00 - Conversion To Resource Family - Release Of Information
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1State of California — Health and Human Services Agency
California Department of Social Services
CONVERSION TO RESOURCE FAMILY:
RELEASE OF INFORMATION
Name of Foster Family Agency: ___________________________________________________
Certified Parent Name #1: _______________________________________________________
(Print Name)
Certified Parent Name #2: _______________________________________________________
(Print Name)
RELEASE OF INFORMATION:
I/We, _________________________________ and, __________________________________
(Print Parent Name #2)
(Print Parent Name #1)
hereby authorize the
Department
_____________________________________________
(County Adoption Agency Name)
or
_____________________________________________ to copy my/our approved adoption
(Adoption Agency Name)
homestudy and any updates to my/our adoption homestudy from my/our adoption file and for said
copies to be placed in my/our Resource Family file for the purpose of being deemed a Resource
Family pursuant to Health and Safety Code section 1517. A closed homestudy cannot be accepted
for deeming purposes.
Upon approval as a Resource Family, I/we understand that my/our certified family home certificate of
approval shall be forfeited by operation of law.
______________________________________________________________
____________
(Date)
(Parent Name #1 Signature)
______________________________________________________________
____________
(Date)
(Parent Name #2 Signature)
_____________________________________________________________
____________
(Date)
(FFA Worker Name)
_____________________________________________________________
____________
(Date)
(FFA Worker Signature)
_____________________________________________________________________________
(FFA Worker Address)
__________________________
(FFA Worker Telephone Number)
LIC 00 (8/17) (Mandatory)
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