General Application for Potential Providers

General Application for Potential Providers

If you are in a two-parent household, a separate application needs to be submitted by both parents.

Required fields are marked with a red asterisk*. If a required field is not applicable to you, write N/A in the blank.

NOTE: Your answers are not saved until you complete the form and click Submit at the end. There is no time limit, so you can take a break and return to this page later, but this page must remain open until you are finished. If you get an error when you click Submit, click your browser's Back button one time. Then try clicking submit again.

  • Personal Information

  • Description of Current Residence/Home Environment:

  • **Please note that each pet must have annual Rabies Vaccination for your home to be licensed. **
  • Motor Vehicle Information:

  • Members of the Household:

    (Include other adults, borders, children, etc.)
  • Family Members not Living in the Home:

    (Grown Children) State standards require references be sent to adult children or contacted.
  • In Case of Emergency, Please Notify:
  • Education Background:

  • Employment History: (last 10 years)

  • Medical Background:

  • *******Please note that TB tests are required by each family member for your home to be licensed.
  • Criminal History:

  • Note: A background check will be completed on the applicants and any household member 14 years of age and older as well as frequent visitors to the home. Frequent is defined as more than twice in a 30-day period.

    The following may preclude any person from being a foster parent, being a household member in the foster home or being a frequent visitor in the foster home; Any misdemeanor or felony such as, offenses against a person, robbery, public indecency, stalking, solicitation of a minor, failure to stop or report aggravated sexual assault of a child, making a firearm accessible to a child, intoxication offenses, any felony and any deferred adjudication of any of the above.

    Any other charges a person may have will be evaluated and assessed if we will allow licensure; some of the factors used in our assessment include the type of charge, the length of time since the charge, and the age of the applicant at the time of the charge.

  • Residence History (Past 10 Years)

    Full Physical Addresses are Required
  • Local and Community Resources:

  • What school would a foster child attend? Give addresses and phone numbers:
  • Special Skills and Interests:

  • General Questions:

  • What do you think would make a child:
  • Subjective Questions:

  • My family raised me to value:
  • My three greatest strengths are:
  • My three greatest weaknesses are:
  • References:

    **Full names and addresses with zip code must be provided**
  • Family Member:
  • Non-Family Members (2)
  • Employer/Co-worker:
  • ******Full Address with ZIP CODE must be included*****
  • Circles of Care- Behavior Tolerance Checklist

  • This sheet is to be completed as part of your licensing procedure. This list will be reviewed with the COC worker and specific areas will be discussed. It will be used in the consideration of future placements. Select the choice which best describes your family’s reaction to each item and your ability to work with such behaviors and issues. Make additional comments if appropriate. If husband and wife differ in their opinion, they may indicate this in the additional comments field. Designate “H” for husband and “W” for wife.
  • By entering your name, you are signing the above form and verifying that all information is correct.
  • You Are Almost Done!

    This is the final page of the application. Your application has not been submitted yet. Please read the information on this page and fill out the signature fields at the bottom. Then click on "Submit" and wait for the confirmation message to appear. If you do not see a confirmation message, contact Circles of Care for assistance.

    Right of Refusal to Deny Licensure & Fee Reimbursement Policy Acknowledgement

    Circles of Care reserves the right to deny licensure of foster care or adoption applicants at any time during the licensing process.

    Foster and Adoptive Parents who apply with Circles of Care apply as potential providers to be licensed by Circles of Care. The licensing procedure is a “process” that involves many steps and has many requirements. Some of the steps include an FBI check, home study, training, background check and home inspections. Every step and requirement is an opportunity for Circles of Care to evaluate the applicants to determine if the applicants are a good fit for our agency and can meet the needs of the children we serve. Circles of Care reserves the right to deny potential foster and adoption applicants at any time during the licensing process.

    Circles of Care is not responsible for any lost work or wages for the time or effort the applicant spends to go through the licensing process, regardless of whether or not the licensure occurs.

    In addition, as part of the licensing process, there are certain requirements to include: FBI background checks, Fire Inspections, Health Inspections and TB testing that incur a cost to the applicants. Circles of Care reimburses up to a certain amount for inspection fees and TB testing. The reimbursement amount Circles of Care will pay can change from year to year based on budgets. Applicants need to inquire and know the current reimbursement for these costs and factor that into their decision to pursue licensure.

    Applicants are not to schedule or obtain these requirements that have associated fees, unless specifically instructed to do so by Circles of Care. The reimbursement amounts provided by Circles of Care will only be paid to the applicant if Circles of Care had specifically instructed the applicants to obtain these requirements.

    No supplies or repairs that may be required to pass such inspections are paid for by Circles of Care nor reimbursed to the applicant regardless of whether or not the applicant is licensed.

    Fire and Health Inspections Acknowledgment

    As part of the assessment to license a potential foster home, all homes must receive fire and health inspections from the county health department and the city or state fire departments. Once licensed, these inspections are required to be repeated every two (2) years for regular homes and for group homes, once every year.

    Circles of Care will reimburse homes for some of the cost of the inspections. Inspection fees range by city and county and the amount Circles of Care will reimburse can change based on budgets. Please inquire about what the current inspection fee reimbursement is and factor that in to your decision to purse licensure. For new potential homes, this reimbursement is done after the home is officially licensed or denied and for current homes, once the inspection reports have been turned in to Circles of Care.

    Circles of Care reimburses for the inspection fee cost only. Circles of Care does not pay or reimburse for anything that is required to be done to your home to pass these inspections such as having fire alarms, fire extinguisher or repair and maintenance that the inspectors feel is needed on your home.

    Common things needed to pass inspections:

    For Fire:
    Fire Extinguisher
    Fire Alarms on each floor if 2 story
    Carbon Monoxide detector if home is equipped with gas
    A/C unit serviced or checked out by AC Company

    For Health:
    First Aid kit
    Child cover protectors on electrical outlets

  • By entering your name, you are signing the above form and verifying that all information is correct. If you are in a two-parent household, a separate application needs to be submitted by both parents.
  • If you are in a two-parent household, a separate application needs to be submitted by both parents.

    Once you click Submit, wait for the confirmation message to appear. If you get an error when you click Submit, click your browser's Back button, then try clicking submit again. Do not use your browser's refresh button unless you want to clear the form and start over.

  • This field is for validation purposes and should be left unchanged.