Newsletter (copy) - Plummer Youth Promise

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First Name*

Last Name*

Home Phone

Cell Phone*

Email Address*

Home Address*

Street Address Address Line 2 City State ZIP Code

Who lives in the home?*

Age of all household members?*

Anyone 14 years or older residing in your home will need to complete a CORI form

Have you had any history or involvement with the Department of Children and Families (DCF)?*

Do you think anything will show up on your background record check? (Bounced check, Court-related ticket)*

In the last five years, have you lived outside of Massachusetts? If yes, where?*

Is anyone in your home providing daycare or adult care?*

How many bedrooms are in the home?*

Would foster youth placed in your home be sharing a bedroom or have their own?*

Are any bedrooms located on the third floor or basement?*

Do you have any pets? If yes, what kind and how many?*

Note: Youth under 12 cannot be placed in a home with a German Shepherd, Pit Bull, Rottweiler, or a mix of these breeds

Are you currently employed or have a stable source of income?*

Do you have a car? License? Car insurance and active registration?*

If unavailable, do you have backup support to help you with foster youth? (2 backups are ideal)*

Have you been MAPP Trained (Massachusetts Approach to Partnerships in Parenting Program)?*

How did you hear about Plummer’s Foster Care Family Program?

Word of Mouth

Google

Other Internet Source

Other

Additional Comments/Notes*