Form DCF-047 "Application for Foster Care License" - Connecticut

What Is Form DCF-047?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2017;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-047 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-047 "Application for Foster Care License" - Connecticut

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Connecticut Department of Children and Families
APPLICATION FOR FOSTER CARE LICENSE
DCF-047
6/17 (Rev.)
(
Attach additional pages if necessary
)
Page 1 of 9
FOR DCF USE ONLY
Type of Placement:
Adoption
Foster Care
Fictive Kin
Independent
Relative
Respite Caregiver
Assigned FASU SW:
REQUIRED Checks:
Check Completed?:
Protective Services Checks
Yes
Date
Attached
Pending
DCF Office:
CMS Search
DMV
Please Select DCF Office
SW Phone:
LINK Search
Childcare License (OEC)
APPLICANTS TO COMPLETE PAGES 1-9
Parent #1
Parent #2
LAST Name:
FIRST Name:
M:
LAST Name:
FIRST Name:
M:
Birth Name (if applicable):
AKA (if applicable):
Birth Name (if applicable):
AKA (if applicable):
DOB:
Race:
DOB:
Race:
Please Select One
Please Select One
Birth Place:
Religion, if any:
Birth Place:
Religion, if any:
CT Driver’s License #
Social Security #:
CT Driver’s License #
Social Security #:
Language(s):
Home Phone:
Language(s):
Home Phone:
Work Phone:
Cell Phone:
Work Phone:
Cell Phone:
E-mail:
E-mail:
Military Service:
Duty Status:
Type of Discharge:
Military Service:
Duty Status:
Type of Discharge:
Address: (No. and Street):
City:
State:
Zip:
Connecticut
How long have you lived at your current address?:
How long have you lived at your current address?:
LIST PREVIOUS ADDRESSES IN THE LAST FIVE YEARS (If applicable)
Parent #1
Parent #2
Connecticut Department of Children and Families
APPLICATION FOR FOSTER CARE LICENSE
DCF-047
6/17 (Rev.)
(
Attach additional pages if necessary
)
Page 1 of 9
FOR DCF USE ONLY
Type of Placement:
Adoption
Foster Care
Fictive Kin
Independent
Relative
Respite Caregiver
Assigned FASU SW:
REQUIRED Checks:
Check Completed?:
Protective Services Checks
Yes
Date
Attached
Pending
DCF Office:
CMS Search
DMV
Please Select DCF Office
SW Phone:
LINK Search
Childcare License (OEC)
APPLICANTS TO COMPLETE PAGES 1-9
Parent #1
Parent #2
LAST Name:
FIRST Name:
M:
LAST Name:
FIRST Name:
M:
Birth Name (if applicable):
AKA (if applicable):
Birth Name (if applicable):
AKA (if applicable):
DOB:
Race:
DOB:
Race:
Please Select One
Please Select One
Birth Place:
Religion, if any:
Birth Place:
Religion, if any:
CT Driver’s License #
Social Security #:
CT Driver’s License #
Social Security #:
Language(s):
Home Phone:
Language(s):
Home Phone:
Work Phone:
Cell Phone:
Work Phone:
Cell Phone:
E-mail:
E-mail:
Military Service:
Duty Status:
Type of Discharge:
Military Service:
Duty Status:
Type of Discharge:
Address: (No. and Street):
City:
State:
Zip:
Connecticut
How long have you lived at your current address?:
How long have you lived at your current address?:
LIST PREVIOUS ADDRESSES IN THE LAST FIVE YEARS (If applicable)
Parent #1
Parent #2
Page 2 of 9
CURRENT MARRIAGE OR RELATIONSHP STATUS
Other relationship status, please explain:
Single
Divorced
Not currently married
Divorce pending
Widowed
Married, but Separated
Date of Current Marriage:
Date started living together (if not married):
PREVIOUS MARRIAGES OR RELATIONSHP(S)
Parent #1
Parent #2
1.
Name of Previous partner (if applicable):
1.
Name of Previous partner (if applicable):
Type of Previous relationship:
Marriage
Relationship
Type of Previous relationship:
Marriage
Relationship
From (enter dates):
To:
From (enter dates):
To:
Reason for ending the relationship:
Death
Divorce
Separation
Reason for ending the relationship:
Death
Divorce
Separation
2.
Name of Previous partner (if applicable):
3.
Name of Previous partner (if applicable):
Type of Previous relationship:
Marriage
Relationship
Type of Previous relationship:
Marriage
Relationship
From (enter dates):
To:
From (enter dates):
To:
Reason for ending the relationship:
Death
Divorce
Separation
Reason for ending the relationship:
Death
Divorce
Separation
EMPLOYMENT INFORMATION
Parent #1
Parent #2
Name of Employer:
Name of Employer:
Date of Hire:
# of hours worked
Date of Hire:
# of hours worked
each week:
each week:
Position
Work Phone:
Position
Work Phone:
Do you have a Second Job?
Name of Second Employer:
Name of Second Employer:
Date of Hire:
# of hours worked
Date of Hire:
# of hours worked
each week:
each week:
Position
Work Phone:
Position
Work Phone:
EDUCATIONAL BACKGROUND
Parent #1
Parent #2
Highest Grade Completed (including college):
Highest Grade Completed (including college):
Name of High School or Trade School:
Name of High School or Trade School:
Name of College or University:
Name of College or University:
If appropriate, which area of study?:
If appropriate, which area of study?:
Page 3 of 9
EMERGENCY - In case of emergency, list at least TWO persons who can be contacted
1.
Name:
Relationship:
Work Phone:
Cell Phone:
Home Phone:
Address: (No. and Street):
City:
State:
Zip:
2.
Name:
Relationship:
Work Phone:
Cell Phone:
Home Phone:
Address: (No. and Street):
City:
State:
Zip:
3.
Name:
Relationship:
Work Phone:
Cell Phone:
Home Phone:
Address: (No. and Street):
City:
State:
Zip:
OTHER ADULT MEMBERS OF HOUSEHOLD (Over the age of 18, if applicable)
LAST Name:
FIRST Name:
Birth Name:
AKA:
DOB:
Relationship to Applicant:
Occupation:
CHILDREN LIVING IN THE HOUSEHOLD (Under the age of 18, if applicable)
LAST Name:
FIRST Name:
DOB:
Name of School:
Grade:
CHILDREN NOT LIVING IN THE HOUSEHOLD WITH YOU (if applicable)
LAST Name:
FIRST Name:
DOB:
Name of School:
Grade:
ADULT CHILDREN NOT LIVING IN THE HOUSEHOLD WITH YOU (if applicable)
LAST Name:
FIRST Name:
DOB:
Occupation / Employer (if applicable)
FREQUENT VISITORS
LAST Name:
FIRST Name:
DOB:
Address where they live?:
Page 4 of 9
HOW DID YOU HEAR ABOUT FOSTER CARE OR ADOPTION? (Check all that apply)
Newspaper
Phone Book
Radio
Television
Referral from a current Foster or Adoptive Parent
Facebook
Twitter
Internet
House of Worship
Other:
Have you or anyone regularly residing in your home, or any substitute caregiver, previously applied or been licensed for foster care or adoption by the
Department of Children and Families or any other state or private agency?
Yes
No
If “Yes” please specify when, where and the resulting action:
Are you, or have you been a licensed childcare, adoptive or any other out-of-home care provider by DCF or any other state or private agency?
Yes
No
If “Yes” please specify when, where and the resulting action:
Have you discussed foster care or adoption with every family member?
Yes
No
If “Yes” please explain how your family members feel about foster care or adoption?:
Please explain why you want to become a foster or adoptive parent:
Have you or any other family member experienced any major life changes in the past year? (i.e., death of a family member, marriage, divorce, birth of a child,
adoption of a child, major illness, job loss, or significant financial crisis?
Yes
No
If “Yes” please explain:
Page 5 of 9
In what type of home do you live?
Single Family
Apartment
Mobile Home
Townhouse/Condo
Other:
Do you own or rent your residence?
Own
Rent
Was your residence built before 1978?
Yes
No
Don’t know / Unsure
Is your residence “lead-free”?
Yes
No
Don’t Know / Unsure
If you rent, please provide the name and address of your landlord. Notification will be made to the landlord of you interest in fostering a child in your residence.
Landlord’s Name:
Landlords Phone #:
Landlords E-mail:
Landlords Address: (No. and Street):
City:
State:
Zip:
How many rooms in your home?:
How many bedrooms?
On what floor do you sleep?
On what floor would your foster child sleep?
Do you have a pool, Jacuzzi, hot tub or water on your property?
Yes
No
Is your water supply public or from a well?
Public
Well
If you have a well, has it been inspected by local town officials?
Yes
No
Do you have an auxiliary heating system?
Yes
No
If “Yes”, what type:
Wood
Coal
Solar
Propane
Other, please explain:
Are there any firearms or weapons such as, but not limited to, rifles, assault weapons, shot guns, hand guns, swords, machetes, cross bows or hunting traps on the
property?
Yes
No.
If “Yes” please explain:
Does anyone in the home, or who regularly visits the home, own or use a firearm or weapon such as a rifle, assault weapon, shot gun, hand gun, sword, machete,
cross bow, hunting traps?
Yes
No.
If “Yes” please explain:
If you answered “Yes” concerning weapons, do you have a federal, state or town permit for weapons
Yes
No
If “Yes”, what kind of permit?
If “Yes”, how and where are the weapons stored?
PETS
Do you have any pets in your home?
Yes
No
(If “No”, you may skip the “Pets” section and proceed to “Household Members” below.)
If ‘Yes”, please list the types of pet(s):
How are the pets supervised?:
Do all the cats and dogs have current vaccinations?
Yes
No
Do any of the pets exhibit aggressive behaviors?
Yes
No
Have you ever had any involvement with police or animal control officer due to roaming, aggression or other behavior by your pet?
Yes
No
Has your pet bitten anyone?
Yes
No If “Yes”, please explain:
Veterinarian’s Name:
Veterinarian’s Phone #:
Veterinarian’s E-mail:
Veterinarian’s Address: (No. and Street):
City:
State:
Zip:
Connecticut
Page of 9