Initial Application Long Form
 

Application for Resource Home

NOTE:
(*) = Required Field
When you have completed the form and have submitted, if the page does not display "Thank you for your submission", please scroll back through the form and look for red error messages. Fill in the information that is required and then submit again.

This process may take you 30-45 minutes and please have the following items:

1. Driver's license number
2. Household member's information
3. If licensed childcare provider, please have your license number
4. Briefly describe all household members' criminal background charges
5. Family financial ; monthly earnings~gross & net
6. Approximate costs of child support & alimony, if applicable
7. Benefit and pension costs
8. Balance of checking and saving accounts
9. Monthly expenses including credit card balance & revolving loans, mortgage, rent, auto payment & insurance, gas, electric, water, cable, telephone, etc. (Approximate costs)
10. Health insurance information
11. Income verification ~ (2) paycheck stubs or W2 that you can upload
12. Fire safety escape route written out that can be uploaded (PDF or a picture can be used)

State of Maryland

Caseworker

My Caseworker (*):

(please select your caseworker) Tracey Higgins Andrea Leys Dahlia Freeman Shanice Randall Jenna Matheny

Applicant 1

Full Name (*):
Gender (*):
Email (*):
Address (*):	(include city, state, and zip code)
Telephone (home):
Telephone (work):
Telephone (cell) (*):
Driver's License Number & State:
Have you lived outside of Maryland within the last 5 years? (*):	Yes No
Date of Birth (*):
Place of Birth:
Race:
Ethnicity:	Hispanic/Latino Non Hispanic/Latino
Citizenship:
Primary Language Spoken:
Religious Identification:
Height:
Weight:
Eye Color/Hair Color :
Hearing Impaired:	Yes No
Legally Blind:	Yes No
Declared Disabled:	Yes No
Highest Grade Completed:
Last School Attended:

Other (trainings, etc…):

Relationship Status

If married, date and place:
If separated, date of separation:

Previous Marriages

Please list most recent first

To Whom:
Date:
Place:
End Date:

Terminated by:

To Whom:
Date:
Place:
End Date:

Terminated by:

Employment History

Employer Name & Address:
Occupation:
How long employed?:
Salary:
Working Hours:
Other Income/Source:

 

Applicant 2

Full Name:
Gender:
Email:
Address :	(include city, state, and zip code)
Telephone (work):
Telephone (cell):
Driver's License Number & State:
Have you lived outside of Maryland within the last 5 years? :	Yes No
Date of Birth:
Place of Birth:
Race:
Ethnicity:	Hispanic/Latino Non Hispanic/Latino
Citizenship:
Religious Identification:
Height:
Weight:
Eye Color/Hair Color:
Hearing Impaired:	Yes No
Legally Blind:	Yes No
Declared Disabled:	Yes No
Highest Grade Completed:
Last School Attended:

Other (trainings, etc…):

Relationship Status

 

If married, date and place:
If separated, date of separation:

Previous Marriages

Most recent listed first

To Whom:
Date:
Place:
End Date:

Terminated by:

To Whom:
Date:
Place:
End Date:

Terminated by:

Employment History

Employer Name & Address:
Occupation:
How long employed?:
Salary:
Working Hours:
Other Income/Source:

Total Number of Pets:

Please list kinds of pets:

Provide written directions to the residence:

 

Children (include all children of previous relationships)

Name:
Date of Birth:
Living with whom:

Name:
Date of Birth:
Living with whom:

Name:
Date of Birth:
Living with whom:

Name:
Date of Birth:
Living with whom:

Name:
Date of Birth:
Living with whom:

Others In Home (Children & other adults)

Name:
Date of Birth:
Relationship:

 

Name:
Date of Birth:
Relationship:

 

Name:
Date of Birth:
Relationship:

 

Name:
Date of Birth:
Relationship:

I am/we are interested in the following: (you may check more than one) (*):

Foster Care Adoption Emergency Care Respite Care Treatment Foster Care Providing foster care for or adopting a specific child or children (restricted/kinship/relative)

(Please Explain):

Have you ever previously applied to become a resource parent with another source? :

Private Agency – In-State:	Agency Name:
Public Agency – in MD:	Local Department Name:
Public Agency – Out of State:	Specify State
Private Agency – Out of State:	Specify State and Agency Name:

 

Comments/Additional Information:

Are you a licensed child care provider?:

Yes No

If Yes, license #:

Are you currently applying to be a licensed child care provider?:

Yes No

Have you ever had a license, registration or certification for any type of care denied, suspended or revoked?:

Yes No

If Yes, explain:

Are you caring for anyone in your home that is aged, disabled or handicapped?:

Yes No

Have you or any other person living in your residence ever been convicted of any criminal chargers, or received a Probation before judgment disposition or received a not criminally responsible disposition?:

Yes No

If Yes, explain:

Are you or any other persons living in your residence awaiting a trail on any criminal charges?:

Yes No

If Yes, explain:

Have you or any other persons living in your residence ever been reported for child or adult abuse or neglect?:

Yes No

If Yes, explain:

Family Financial Statement

Income

Monthly Earnings	Applicant 1	Applicant 2
Gross:
Net:
Child Support (*):
Alimony (*):
Benefits/Pensions (*):
Other (Specify):
Other (Specify):

Assets

Checking (*):
Savings (*):
Other (Specify):

Expenses (Combined, If Married Couple)

Monthly Expenses

Housing

First Mortgage:
Second Mortgage:
Rent:
Maintenance:

Utilities

Gas & Electric:
Heat:
Telephone:
Water:
Auto Loans:
Auto Insurance:
Added Transportation Costs:
Food:
Clothing:
Child Care:
Medical:
Entertainment:
Contributions:
Savings:
Retirement Plan/IRA:
Child Support:
Educational Expenses:

Credit Cards

Name	Institution	Monthly Payment	Amount Owed

Other Revolving Loans

Name	Institution	Monthly Payment	Amount Owed

Insurance

Name of Company		Monthly Cost	Coverage
Life:
Health:
Other:

 

Will your Current plan cover adopted children a time of placement and before final decree is obtained?:

Will it cover preexisiting medical conditions of adopted children?:

Resource Parent Income Verification

A recent copy of a current pay stub(s), with date of pay and amount should be attached to this form.

Job Title:
Employer:
Length of Employment:
Supervisor’s Name:
Supervisor’s Phone:
Supervisor’s E-mail:
Pay Stub:
W2:

Attitudes Towards Sexual Issues

Many children entering foster care have been sexually abused. Sometimes we do not know that a child has been sexually abused in the child reveals this to their resource parent. It is therefore very important that resource parents consider how they would respond to children who have been sexually abused. It is also important that resource parents consider what having such a child in their home can mean to them, their spouse and their own children. The following questions are intended to help you – ans your worker – decide if you could effectively manage children who have been sexually abused. If you feel uncomfortable completing any section of this questionnaire – leave it blank and you can discuss it later with your worker.

1. While you were growing up did anyone ever touch you in a way that made you feel uncomfortable? :

If yes, did you tell anyone?:

Were you believed?:

2. As an adult have you ever been the victim of sexual assault? :

If yes, did you receive any help in dealing with this experience?:

3. If you answered “Yes” to questions 1 or 2, how did this experience affect you?:

How would you respond to a child who confides in you for the first time that he/she has been sexually abused?:

What kinds of feelings would you have about the abuser?:

What kinds of feelings would you imagine that the child would have towards the abuser?:

4. Do you feel that masturbation is normal? :

How did your parents feel about it and how did they handle it?:

Would you handle it the same way your parents did or differently? Explain.:

Some sexually abused children masturbate excessively and in public. How would you handle this behavior in a child?:

5. Was sex talked about in your family? :

If not, what feelings or messages about sex were given out?:

Who do you think should provide sex education to children and at what age should it begin?:

6. How would you advise an adolescent who seems to be interested in becoming sexually active or who is already sexually active?:

7. What would you do if the child made sexual advances to you or to a member of your family or to another child? :

8. Is it permissible in your home to walk around in your underwear or in the nude?:

9. Do you typically keep your bathroom and bedroom doors closed when you are inside them?:

10. How would you respond to a child if you discovered that he or she was involved in homosexual activities?:

11. If the child you are fostering has been sexually abused, how much would you tell your extended family or others?:

12. If you are an applicant without children in the home, how will having a child in your life affect your sexual relationship?:

Confidentiality and Information Sharing

When you care for a child for whom the Charles County Department of Social Services is responsible, the Department will provide you with personal information about the child and his/her family. This information is shared with you to assist in your decision to provide care for that child and is important in enabling you to better care for the child.

All resource parents are subject to the same standards of confidentiality as Department of Social Services employees. The Maryland law governing confidentiality as stated in the Maryland Annotated Code (Article 88A, S6) and the Code of Maryland Regulations (COMAR 07 01-02 02 and 07.01. 02 07) requires that you keep confidential any information, which you are given, whether verbally or in writing. This includes how the child entered care, information about birth family circumstances, or the child’s permanency plan. A violation of confidentiality is a misdemeanor, and is subject to a fine, imprisonment or both. Maryland Annotated Code Article 88A, S 6.

1. I/we understand and agree that any information provided to me/us about the child in my/our care and his/her family or previous caregiver is confidential.
2. I/we understand and agree that this information cannot be released to, shared or discussed with anyone except Department of Social Services or Court representatives, Citizens Review Board, or Health Care providers directly involved in providing care or treatment to the specific child. These professionals are bound by the same standards of confidentiality.
3. I/we understand and agree that at the time of placement all significant information may not be known regarding the medical or birth family history, special needs or past behaviors of the child. The Department may provide additional information if it becomes available.
4. I/we understand and agree that no photographs or information about the child, including name, may be released for publication without the consent of the birth parents, child’s legal guardian and the Charles County Department of Social Services. I/we understand that I/we must refer any person who claims to have a release of information to the Department for clearance.
5. I/we understand and agree that any written information concerning the child, and any copies of any such information, will be returned to the Department within 5 days of the child leaving my/our home.

I hereby acknowledge that I have read, understand and agree to the terms of this document (*):

 

Discipline of Foster Children

(Code of Maryland Regulations 07.02.25.19)

1. Only foster parents or other adult caregivers approved by the local department and known to the children shall discipline foster children.

2. Physical holding as a form of restraint shall be used only to the degree necessary to protect the child from self-injury or from injuring others.

3. Discipline training and continuing consultation shall be provided by the local department as needed to foster parents regarding appropriate discipline methods. The use of discipline shall also be discussed routinely in the periodic reconsideration of the foster home.

4. Prohibited punishments include the following:

• Corporal punishment, which includes physical hitting or any type of physical punishment inflicted in any manner upon the body;
• Physical exercised, such as running laps or performing push-ups;
• Requiring or using force to require a child to take an uncomfortable position such as squatting, bending or repeated physical movements;
• Verbal remarks which belittle or ridicule a child or a child’s family;
• Denial of essential program services, such as local department planned educational, psychiatric or psychological services;
• Denial of means, clothing, bedding, sleep, mail, or visits with a child’s family;
• Threatening the child with the loss of the child’s placement in the home;
• Bodily shaking;
• Placement in a locked room; and
• Use of mechanical or chemical restraints.

I acknowledge that I have received and understand the State Policy on the use of Corporal Punishment. I understand the use of corporal punishment or other unacceptable methods of punishment may result in the immediate removal of all foster/pre-adoptive children from my home, and is grounds for revoking my home approval. (*):

 

Emergency Preparedness Form

I/we understand and agree to:

1) The need for the local department of social services to have the following information as a part of their local Emergency Preparedness Plan for foster children that may be in our care.

2) To keep the worker informed as soon as possible of any changes in contact information, including changes in work telephone numbers, home telephone numbers and cell phone numbers, etc.

3) To seek permission in advance from the child’s worker for any out-of-state travel and to give additional contact information in the event of out-of-state travel.

4) To notify the child’s worker in advance if a child is to be away overnight for any reason and to provide additional contact information.

5) To do our best to provide care for any foster children placed in our home during an emergency situation, even if we have to leave our home or the area, and to notify the local department as soon as possible of changes in our whereabouts.

In addition, I/we agree to cooperate with the department of social services regarding any other actions that may be needed to implement the local department emergency preparedness plan in the event of emergency.

By checking this box, I acknowledge that I understand the terms and condition of this form: (*):

Fire Safety Survey

This form should be completed by the applicant as part of the home approval process. Please upload a Diagram of Escape Routes from your Home.

Telephone (Does the home have a working telephone?):

Smoke Detector (Is there a working battery Operated smoke detector located on each level of the home?):

Escape Rooms (Are there at least two ways of escape from each bedroom?):

If one way of escape from the bedroom is through a window, is that window large enough to allow ready exit for every child in the home?:

Are the ways of escape from each bedroom free of object that would prevent easy exit?:

Is there an organized plan for getting all individuals safely and quickly out of the home in the event of a fire?:

Flammables (Are highly flammable items kept away from heating and cooking units?):

Address (Can you clearly see the house number from the street?):

Upload Diagram of Escape Routes:

 

Agency

Charles County Department of Social Services, 200 Kent Avenue, La Plata, MD 20646

Smoking Policy Directive

Purpose

This policy directive provides guidelines to ensure that all children in public foster family placements are residing in smoke free environments, free from harmful and toxic effects of secondhand smoke.

Background

In recent years, the affects of secondhand smoke on children has been the topic of much research and discussion. Organizations such as the United States Environmental Protection Agency all concur that children suffer from severe health problems resulting from exposure to secondhand cigarette smoke. For this reason, the Maryland Department of Human Resources initiated a change to the Code of Maryland Regulations (COMAR) 07.2.25.08A(17), to protect Maryland’s foster children from harmful effects of secondhand smoke.

Documented Research Pertaining to Secondhand Tobacco Smoke

The United States Environmental Protection Agency’s Smoke-Free Homes and Cars Program indicates that for families with children, if one smokes, the safest place to smoke is outside. According to the Centers for Disease Control and Prevention, children are powerless to protect themselves from the harmful effects of secondhand smoke, so it is recommended that all families with children maintain smoke-free homes and cars.

Effects of Secondhand Smoke on Children

Recent studies have indicated that there are numerous carcinogens contained in secondhand smoke. The following list indicates some of the health related diseases known to be associated with exposure of children to secondhand smoke.

• Sudden Infant Death Syndrome (SIDS)
• Pneumonia
• Bronchitis
• Asthma
• Cough
• Wheeze
• Phlegm
• Breathlessness
• Upper and lower respiratory tract infections
• Middle ear infection which could result in hearing loss

Requirements for Foster Families

COMAR 07.02.25.08A(17), Responsibilities of a Foster Parent, requires foster parents must “Provide an environment for foster children free from exposure to secondhand smoke.” Accordingly, foster parents shall maintain a home in which those areas in which a foster child resides are smoke free. The foster parents shall prohibit all smoking in the presence of their foster child; however, the foster parents may designate a part of the house as a smoking area, provided that a foster child’s access is restricted.

Smoking is prohibited:

1. In the foster family’s home, except for designated smoking area which will not be used by foster children;
2. In a foster family’s vehicles while transporting foster children; and
3. When foster children are present in any home providing respite care or other “back-up” care, except in designated smoking areas which are not used by foster children.

Requirements for Local Departments

The Local Department Recruiter/PRIDE Trainer, the foster family home worker and foster child’s caseworker shall ensure that the foster home is in compliance and that the foster child is in an environment which is smoke free.

• Local Department Recruiters/PRIDE Trainers shall discuss smoke free environments and compliance with this policy directive during information meetings and during pre-service training. The foster family home worker shall make an assessment for compliance with this policy during the approval process, and scheduled home visits. Reconsiderations, the effects of second hand smoke shall be discussed with foster parents.
• During monthly visits, the child’s caseworker shall:
• Assess to ensure the child is free from exposure to secondhand smoke; and
• Note any concerns in progress notes in CHESSIE

I acknowledge that I have received and understand the State Policy on the use of Corporal Punishment. I understand the use of corporal punishment or other unacceptable methods of punishment may result in the immediate removal of all foster/pre-adoptive children from my home, and is grounds for revoking my home approval. (*):

 

Angel's Law

Dear Foster Parent(s):

The safety of children is a major concern for all of us at OHR. We know that foster parents share this concern. In April 2010, the Maryland Legislature passed "Angel's Law," which requires that all window coverings in public resource homes are safe for children.
"Angel's Law" requires that:

A window covering lnstalled:
(1) Before October 1, 2010, shall not have exposed or unsecured cords, beads, ropes, or strings; or
(2) On or after October 1, 2010, shall be cordless.

All foster parents must be in compliance with the above requirements. Please immediately repair or remove any venetian blinds, mini blinds, vertical blinds, horizontal blinds, roman shades, pleated shades, roll-up shades, or draperies which have any cords, beads, ropes, or strings on the back, side, or front of the product which a child can reach. Failure to comply may result in the removal of foster children from foster homes in violation of Angel's Law.

Resource home workers will be ensuring that all foster homes approved before October 1, 201 0 and have window coverings that were installed before October 1, 201O do not have exposed or unsecured cords, beads, ropes, or strings. Please refer to the pictures attached below for some examples of these types of window coverings and ways to keep the cords out of the reach of children. Resource home workers will also assess all resource homes to ensure that window coverings installed on or after October 1, 2010 are cordless.

For a free repair kit, please contact the Window Covering Safety Council at 1-800-506-4636, or visit their website at windowcoverings.org. The Consumer Product Safety Commission (CPSC) recommends that cordless window coverings be used in all homes where children live or visit.

I hereby acknowledge that I have read, understand and agree to the terms of this document (*) :

Resource Parent Agreement

In becoming resource parents of any child placed with us by the CHARLES County Department of Social Services, I/we understand and agree that the custody and control of the child at all times remains in the Department. Specifically, we understand and agree.

• That the Department will provide board, medical care and supervision of the child during his/her placement,
• That visiting and communication between the child and his/her own family will be arranged by the Department,
• That the length of time a child will remain in my/our home cannot be known at the time the child is placed with me/us,
• That the Department reserves the right to remove any child at its discretion,
• That no child is to be moved from my/our home without the written permission of the Department,
• That I/we reserve the right to ask the Department to take back any child, understanding the time needed to find an alternative placement I/we will give at least 10 working days notice,
• That I/we will take no action for adoption or guardianship of any child placed with me/us by the Department without the Department’s consent in writing,
• That I/we will provide the child with proper clothing for the season,
• That I/we understand that the Department of Human Resources prohibits the use of corporal or unusual punishment on a child in their custody and placed in my/our home. This includes the following methods of punishment:
  • Spanking, slapping, switching, or hitting a child;
  • Shaking, pinching, biting, twisting or pulling;
  • Tying a child with a rope or similar item;
  • Withholding of food or force feeding;
  • Denying mail, family visits, telephone contacts with family or activities with the Services Worker or other Department staff;
  • Criticizing the child’s family or the child’s experiences with the family;
  • Humiliating or degrading punishment that subjects the child to ridicule, such as the following:
• Cutting or combing the child’s hair for punishment,
• Name calling and public scolding,
• Forcing any child to wear clothing or accessories usually associated with the other sex,
• Forcing the child to perform degrading/humiliating acts (i.e.; behavior associated with younger children or animals);
  • Creating fear, anger, and increased anxiety by threatening a child with removal from the foster home;
  • Locking a child in a room/closet or outside the home;
  • Group punishment for the misbehavior of an individual child;
  • Delegating authority or allowing punishment by other children or adults;
  • Destroying the child’s property; and
  • Any other practice(s) which may physically or emotionally damage the child.

I/we understand that violation of the discipline policy and the decisions made are not subject to appeal at State Level. Decisions made as a result of Child Protective Services (CPS) investigations are not grievable under the Foster Parent Grievance Procedures. Even though a CPS investigation may be unconfirmed or unfounded, the foster home may still be closed as a result of issues/concerns arising from the investigation.

I hereby acknowledge that I have read, understand and agree to the terms of this document:

 

IMPORTANT

If you do not see "Thank you for your submission", after you press the red Submit button, please scroll back through the form and look for red error messages. Fill in the information that is required and then submit again. Unless you see the 'Thank you for your submission' message, we did not receive your application.