Lauren GlassmanDirector, Foster Home Services glassmanla@jccany.orgContact us Step 1 of 7 14% Prospective Foster Parent Questionnaire Thank you for your interest in joining JCCA's Foster Care Program. Please answer the questions in this form to help us determine how best to proceed with your introduction to fostering in our program.Personal InformationWhat is your name?(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address(Required) Phone Number(Required)Date of Birth(Required) MM slash DD slash YYYY Occupation(Required) Family InformationMarital Status(Required) Single Married Divorced Widowed Other Please specify:(Required)Do you have children of your own?(Required) Yes No Please provide their ages:(Required)Does anyone else live in your household?(Required) Yes No Please provide their relationship to you:(Required) Motivation and CommitmentWhy are you interested in becoming a foster parent? (please describe briefly)(Required)How did you learn about the foster care program?(Required)Are you prepared to commit to the responsibilities of being a foster parent, including regular training, meetings, and interactions with the child's birth family?(Required) Yes No Unsure Experience and SkillsDo you have any previous experience working with children or youth?(Required) Yes No Please describe your experience:(Required)Have you received any training or education related to childcare or parenting?(Required) Yes No Please describe your past training or education:(Required)Are you comfortable managing behavioral challenges and providing emotional support to children?(Required) Yes No Unsure Preferences and AvailabilityWhat age range are you interested in fostering? (check all that apply)(Required) 0-5 Years 6-12 Years 13-17 Years 18-21 Years Are you open to fostering children with special needs or medical conditions?(Required) Yes No Unsure Which types of foster care are you interested in? (check all that apply)(Required) Emergency Placements Short-term Placements Long-term Placements Respite Care Specials Needs Care How soon are you available to begin fostering?(Required) Immediately Within 1 month Within 3 months Longer than 3 months Stability and ResourcesDo you have stable income and housing?(Required) Yes No Do you have a support system (friends, family, community) to assist you in your fostering role?(Required) Yes No Are there any specific supports or resources you would need to be an effective foster parent?(Required) Additional CommentsPlease share any additional thoughts or concerns regarding your interest in fostering: Δ
