We appreciate your interest in Children’s Home Society of North... step in opening your heart and home to a waiting...

We appreciate your interest in Children’s Home Society of North Carolina. You have taken the first
step in opening your heart and home to a waiting child. To begin the process we are attaching
information about our programs, as well as an application and medical history forms for you to
complete and return to us.
Please mail to: Support Services
Children’s Home Society of North Carolina
131 Wind Chime Court
Raleigh, N.C. 27615
The children being referred from Departments of Social Services are of school age, with an average
age of nine, and have been abused or neglected. They may be developmentally delayed or medically
fragile, and some are part of a sibling group who need to stay together in a family. These children
require unconditional love and patience because of their prior experiences and circumstances.
The State of North Carolina requires a completed Responsible Individuals List form, according to 10A
NCAC 70A .0102, for all adult members of the household—to determine they have not had child
protective services substantiate a claim of child abuse or serious neglect. The form is enclosed and
must be completed, signed, and returned to us.
Please feel free to contact our office if you have any questions about the application at 919.676.4784
You might also like to visit our web site at www.chsnc.org.
Again, thank you for your interest. We look forward to working with you in the future as we strive
toward improving the lives of children in the foster care system.
Page 1 of 4
Application for Foster Care/Adoption Services
CHILDREN'S HOME SOCIETY OF NORTH CAROLINA
Website: www.chsnc.org
Name of Applicant(s): ____________________________________________________________________________________
Address:________________________________________________________________________________________________
Street
City
State
Zip
County
Home Telephone: _______________________ How did you learn about our agency? ______________________________
1) Applicant One: Full Legal Name: ____________________________________________________________ Age: _______
First
Middle
Last
Other Names Known By (i.e. previous married names/alias): ____________________________________________________
Cell: _________________ Work: ______________ E-mail address: _____________________________________________
Date of Birth: ___________________ Birthplace: ___________________________________________________________
City
Race:______________ Sex: _________ Height:
Circle One: Single
Married
Separated
County
Weight:
Divorced
State
Religious Affiliation: ______________________
Widowed
Legal Resident of NC? Yes ____ No _____
Education:____________________________________________________________________________________________
(Highest level reached; Certificate, GED, Diploma, or Degree received, grammar school, high school, college or other)
Do you have a valid driver’s license? Yes _____ No _____
Employer: ________________________________________________________City/State:___________________________
Occupation/Job Title: ___________________________________________ Length of Employment: ____________________
Full Time: _______ Part Time: _______ Work Hours: _____________________ Salary: ___________________ per month
Explain: ________________________________________________________
Any Serious Health Problems?
How long have you lived at your current address: _____________________________________________________________
If less than 5 years, please give addresses for the last five years:
__________________________________________________________________________ From: __________ To: _________
Street
City
State
Month/Year
Month/Year
__________________________________________________________________________ From: __________ To: _________
Street
City
State
Month/Year
Month/Year
__________________________________________________________________________ From: __________ To: _________
Street
City
State
Month/Year
Month/Year
2) Applicant Two: Full Legal Name: ____________________________________________________________ Age: _______
First
Middle
Last
Other Names Known By (i.e. previous married names/alias): ____________________________________________________
Cell: _________________ Work: ______________ E-mail address: _____________________________________________
Date of Birth: ___________________ Birthplace: ___________________________________________________________
City
County
State
Page 2 of 4
Race:______________ Sex: _________ Height:
Circle One: Single
Married
Separated
Weight:
Divorced
Religious Affiliation: ______________________
Widowed
Legal Resident of NC? Yes ____ No _____
Education:____________________________________________________________________________________________
(Highest level reached; Certificate, GED, Diploma, or Degree received, grammar school, high school, college or other)
Do you have a valid driver’s license? Yes _____ No _____
Employer: ________________________________________________________City/State:___________________________
Occupation/Job Title: ___________________________________________ Length of Employment: ___________________
Full Time: _______ Part Time: _______ Work Hours: _____________________ Salary: ___________________ per month
Any Serious Health Problems?
Explain: ________________________________________________________
How long have you lived at your current address: _____________________________________________________________
If less than 5 years, please give addresses for the last five years:
__________________________________________________________________________ From: __________ To: _________
Street
City
State
Month/Year
Month/Year
__________________________________________________________________________ From: __________ To: _________
Street
City
State
Month/Year
Month/Year
__________________________________________________________________________ From: __________ To: _________
Street
City
3) Are you primarily interested in:
______ Adoption
State
Month/Year
Month/Year
_____Foster Care
Are you currently, or have you ever been a licensed Foster Parent? Yes ____ No ____
If checked yes, which agency? (Agency name & address): _______________________________________________________
______________________________________________________________________________________________________
Licensed From: __________ (Month/Year) To: ___________ (Month/Year)
Are you an Adoptive Parent? Yes ____ No ____
If checked yes, which agency? (Agency name & address): _______________________________________________________
______________________________________________________________________________________________________
4) Has anyone in the household been charged or arrested with any offense? Yes _____ No _____
If yes, when? _______________________________ On a separate sheet, please explain what happened.
Have you ever been investigated by any Dept. of Social Services regarding child abuse or neglect? Yes ____ No _____
If yes, when? ___________________________(Month/Year) Was the case substantiated? Yes ____ No ____ Unknown _____
If yes, please explain what happened on a separate sheet of paper.
5) Facts About Marriage and Children:
Marriage Date: ___________________ Place of Marriage: ______________________________________________________
Previous Marriages: Applicant One-Date:
How Terminated:
Date Terminated: ____________
Applicant Two-Date: __________ How Terminated:
Date Terminated: ____________
Page 3 of 4
Please list children of this or previous marriages, giving name, age, sex, whether born to you or adopted by you. If adopted, please
give agency of adoption. Use separate sheet of paper if needed.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
6) Additional Financial Information:
Other resources such as savings, investments, real estate, etc: _____________________________________________________
If renting, please give monthly rate:
Valuation of home if owned: __________________________
Is there a mortgage on your property? ______________________ Monthly payment: _________________________________
7) Questions related to your plan to adopt or foster a child or children
Most children have serious and/or major health problems and may include any of the following special needs. Please indicate
your willingness to consider the following:
Hearing
Orthopedic
Sickle Cell
Alcohol Abuse
Prematurity (less than 32 wks)
Sight
Psychiatric Diagnosis
HIV
Drug Abuse
Mental Retardation
Emotional needs
Behavioral problems
Therapy/Counseling Sexual Abuse
Learning disability
Medically Fragile Developmental Delays Speech issues
Gender Identity
Sexualized Behavior
a) Would you consider a child or children of the following ages? (Please circle ALL preferences)
13 or older
10-12
6-9
b) Would you consider a family of children of the following numbers? (Please circle preferences)
1
2
3
4
5
c) Do you own or operate a home day care, after school care, or otherwise provide any form of childcare? Yes ___ No ___
d) Foster/Adoptive parents are expected to transport a foster or adoptive child to appointments, meetings,
court appearances, etc. Is there anything which would prevent you from doing so?
Yes ___ No ___
If yes, please explain: ____________________________________________________________________________
______________________________________________________________________________________________
8) Are you interested in applying for a specific child or children? If yes, specify name(s), ID #, or agency:
___________________________________________________________________________________________________
No ____ Date Completed MAPP: __________
9) Are you in the process of application with another agency? Yes
If yes, specify name of agency:__________________________________________________________________________
10) Have you ever worked with Children's Home Society of NC? Yes_____ No _____ If yes, when? _________________
I understand that it is my privilege to withdraw my application at any time if I do not wish to continue the process for adoption/foster care licensing through Children's
Home Society. I further understand that I am under no obligation to explain my reason to the agency. Likewise, I understand that CHS may not give us a specific
reason if the agency chooses at any point not to proceed with our application for adoption or foster care licensing. The completion of MAPP or any other group
training process does not guarantee adoption or foster care licensing. I certify that all information given by me in this application process is correct and complete to
the best of my knowledge and any willful misrepresentation of this information disqualifies my application.
CHS has a commitment to respond to each client with respect and to ensure quality services and equal application of policies and procedures. All client information and
contacts are handled confidentially. A copy of the CHS grievance policy and confidentiality statement will be given to you at your first interview.
CHS does not discriminate on the basis of race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, or mental or physical
disability. CHS also adheres to the regulations set forth in the Indian Child Welfare Act.
SIGNED: Applicant One:
Date: __________________________
Applicant Two:
Date: _________________________
****************************************************For Office Use Only ***********************************************************
Date of Inquiry: ____________ Date Application Received: ______________ Case #: _______________________ Made Case Date: _______________
Program: ___________________ SW Assigned: _____________________________ Assigned Date: ______________ Region: __________________
Rev.10/11
Page 4 of 4
MEDICAL HISTORY FORM
NORTH CAROLINA DIVISION OF SOCIAL SERVICES
Name: ______________________________________________________________________
Home Address: _______________________________________________________________
Phone: ___________________________________ Date of Birth: _______________________
HEALTH HISTORY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Any history, past, or present of:
Head or back injuries
Neurological disorders, convulsions, etc.
Heart disease, high blood pressure, or rheumatic fever
Lung disorders, asthma, tuberculosis
Stomach, gall bladder, or other gastro-intestinal disorders
Allergies to food, drugs, plants, etc.
Blood disorders, anemia, leukemia, etc.
Kidney trouble
Venereal disease
Diabetes or other glandular disorders
Surgery
Physical disabilities
Psychological disorders, mental health diagnosis, drug/substance abuse
Other chronic illnesses, diseases, or disorders
YES
NO
If any of the above questions were answered yes, provide explanation:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
What do you consider your state of health: Excellent
Good
Fair
Poor
To the best of my knowledge, the above information is correct.
____________________________________________________ ________________
Signature
Date
DSS-5017 (Rev. 04/11)
Child Welfare Services
MEDICAL HISTORY FORM
NORTH CAROLINA DIVISION OF SOCIAL SERVICES
Name: ______________________________________________________________________
Home Address: _______________________________________________________________
Phone: ___________________________________ Date of Birth: _______________________
HEALTH HISTORY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Any history, past, or present of:
Head or back injuries
Neurological disorders, convulsions, etc.
Heart disease, high blood pressure, or rheumatic fever
Lung disorders, asthma, tuberculosis
Stomach, gall bladder, or other gastro-intestinal disorders
Allergies to food, drugs, plants, etc.
Blood disorders, anemia, leukemia, etc.
Kidney trouble
Venereal disease
Diabetes or other glandular disorders
Surgery
Physical disabilities
Psychological disorders, mental health diagnosis, drug/substance abuse
Other chronic illnesses, diseases, or disorders
YES
NO
If any of the above questions were answered yes, provide explanation:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
What do you consider your state of health: Excellent
Good
Fair
Poor
To the best of my knowledge, the above information is correct.
____________________________________________________ ________________
Signature
Date
DSS-5017 (Rev. 04/11)
Child Welfare Services
North Carolina Division of Social Services
Responsible Individuals List (RIL) Information Request
Instructions for completing DSS-5268 (please read carefully):
Employee (E), Applicant (A) or Volunteer (V)
G.S. § 7B-311 authorizes the release of information regarding
substantiated cases of abuse and serious neglect from the Responsible
Individuals List (RIL), for the sole purpose of determining current or
prospective employment in certain situations, or fitness to provide care for
children. This includes applications to foster or adopt a child.
Print E, A, or V’s Full Name (including MI):
_________________________________________________
First Name
MI
Last Name
E, A, or V’s Date of Birth (MM/DD/YYYY):
All sections of this form must be completed and signed by the agency
and the prospective employee/applicant/volunteer.
Please print legibly or type all information. Incomplete or illegible
forms will be returned via fax without the RIL check being completed.
Requests for information may be submitted by:
Fax:
(919) 715-6714, Attn: RIL
Mail:
Please include a self-addressed stamped envelope.
NC Division of Social Services
Attn: RIL
325 N. Salisbury St.
Mail Service Center 2408
Raleigh, North Carolina 27699-2408
Agency Requesting Information
______/______/______
E, A, or V’s Social Security Number (last four digits)
______ ______ ______ ______
E, A, or V’s Gender: ___ Male
___ Female
Other names used (maiden, nickname, former married name
etc.):
_______________________________________________
_______________________________________________
Employee (E), Applicant (A), or Volunteer (V)
Acknowledgement:
Mailing
Address:____________________________________________________
I acknowledge that I have been informed that the North
Carolina Division of Social Services will disclose to the
above named agency whether my name appears on the
Responsible Individuals List, indicating that I am
identified as being responsible for the abuse or serious
neglect of a juvenile.
City/State/Zip:________________________________________________
Signature:_______________________________________
Phone:______________________________________________________
Date:
Agency
Name:______________________________________________________
________________________________________
FAX:_______________________________________________________
Type of Agency (Check One)
__ Child Care Provider
__ Child Placing Agency
__ Group Home Facility
__ Other Provider of Adoption
__ Adoption Home Study
NCDSS Office Use Only
__
__
__
__
__
Child Caring Institution
County DSS
Guardian ad Litem
Other Provider of Foster Care
Foster Parent Applicant
Agency License Number (if available)_____________________________
Agency Certification: I herby request information from the North Carolina
Responsible Individuals List. I certify that I am a person representing a child
caring institution, child placing agency, group home facility, or a provider of
foster care, child care or adoption services that needs to determine the fitness
of individuals to care for or adopt children. I either currently employ the
individual listed below, or am strongly considering the individual for an
employment, contract, or volunteer position. I will only use the information
requested to determine whether to hire or retain the individual.
Name and Title: (PRINT)
___________________________________________________________________
____ Form submitted incomplete
____ Ineligible to request information
____ As of __________________ E, A, V’s name is NOT on the RIL
____ As of____________________ E, A, V’s name is on the RIL
Finding:
_____________________________________________________
_____________________________________________________
Completed by:
Staff Name (Print):
_____________________________________________________
Signature:
___________________________________________________________________
Signature:
_____________________________________________________
Date:________________________________________________
DSS-5268 (rev. 08/12)
Child Welfare Services
North Carolina Division of Social Services
Responsible Individuals List (RIL) Information Request
Instructions for completing DSS-5268 (please read carefully):
Employee (E), Applicant (A) or Volunteer (V)
G.S. § 7B-311 authorizes the release of information regarding
substantiated cases of abuse and serious neglect from the Responsible
Individuals List (RIL), for the sole purpose of determining current or
prospective employment in certain situations, or fitness to provide care for
children. This includes applications to foster or adopt a child.
Print E, A, or V’s Full Name (including MI):
_________________________________________________
First Name
MI
Last Name
E, A, or V’s Date of Birth (MM/DD/YYYY):
All sections of this form must be completed and signed by the agency
and the prospective employee/applicant/volunteer.
Please print legibly or type all information. Incomplete or illegible
forms will be returned via fax without the RIL check being completed.
Requests for information may be submitted by:
Fax:
(919) 715-6714, Attn: RIL
Mail:
Please include a self-addressed stamped envelope.
NC Division of Social Services
Attn: RIL
325 N. Salisbury St.
Mail Service Center 2408
Raleigh, North Carolina 27699-2408
Agency Requesting Information
______/______/______
E, A, or V’s Social Security Number (last four digits)
______ ______ ______ ______
E, A, or V’s Gender: ___ Male
___ Female
Other names used (maiden, nickname, former married name
etc.):
_______________________________________________
_______________________________________________
Employee (E), Applicant (A), or Volunteer (V)
Acknowledgement:
Mailing
Address:____________________________________________________
I acknowledge that I have been informed that the North
Carolina Division of Social Services will disclose to the
above named agency whether my name appears on the
Responsible Individuals List, indicating that I am
identified as being responsible for the abuse or serious
neglect of a juvenile.
City/State/Zip:________________________________________________
Signature:_______________________________________
Phone:______________________________________________________
Date:
Agency
Name:______________________________________________________
________________________________________
FAX:_______________________________________________________
Type of Agency (Check One)
__ Child Care Provider
__ Child Placing Agency
__ Group Home Facility
__ Other Provider of Adoption
__ Adoption Home Study
NCDSS Office Use Only
__
__
__
__
__
Child Caring Institution
County DSS
Guardian ad Litem
Other Provider of Foster Care
Foster Parent Applicant
Agency License Number (if available)_____________________________
Agency Certification: I herby request information from the North Carolina
Responsible Individuals List. I certify that I am a person representing a child
caring institution, child placing agency, group home facility, or a provider of
foster care, child care or adoption services that needs to determine the fitness
of individuals to care for or adopt children. I either currently employ the
individual listed below, or am strongly considering the individual for an
employment, contract, or volunteer position. I will only use the information
requested to determine whether to hire or retain the individual.
Name and Title: (PRINT)
___________________________________________________________________
____ Form submitted incomplete
____ Ineligible to request information
____ As of __________________ E, A, V’s name is NOT on the RIL
____ As of____________________ E, A, V’s name is on the RIL
Finding:
_____________________________________________________
_____________________________________________________
Completed by:
Staff Name (Print):
_____________________________________________________
Signature:
___________________________________________________________________
Signature:
_____________________________________________________
Date:________________________________________________
DSS-5268 (rev. 08/12)
Child Welfare Services
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