CAREGIVER APPLICATION UNITY #_________________

Division of Child & Family Services (DCFS) Clark County Department of Family Services (DFS)
Washoe County Department of Social Services (WCDSS)
Be sure that this application is completed in full and all required “separate sheet” attachments have been provided.
Application for (check all that apply): Foster Care Adoption Relative/Specific Name:____________________________
ICPC Contractor (Name of contract agency)____________________________________________

How did you learn about the program: T.V. Radio Newspaper Friend Relative Agency/Court Foster Parent
Other _____________________________________________________________________________________________

Applicant #1 Name (First) _________________________ (Middle)___________________ (Last) ____________________________________

Date of birth Place of birth: City, ________________ State, ________ Country, _____________
_______________________________________________________________________

Social Security #______________________ Driver’s Lic. #_______________________State_____________

RACE/ETHNICITY: Cauc. African American Asian/Pacific Isl. Hispanic Other Identify)_________________________
Native American/Alaskan Native Tribe __________________ Tribal / Member Number: ______________________
Are you a US Citizen? Yes No Legal Resident? Yes No If “Yes”, Resident number ____________________
What languages do you speak? ____________________________________________ Occupation___________________________
Employer ______________________________Address___________________________________________________
Work phone______________________ How long at current job
(If less than five years, please list employment history for past five years by attaching a separate sheet)
Do you have health insurance? Yes No If yes, Agency _________________________________________________
Would your health insurance cover an adopted child? Yes No

Applicant #2 Name (First)____________________ (Middle) _________________ (Last) ___________________________________

Date of birth Place of birth: City, _________________ State, ________ Country, ____________
Social Security #______________________ Driver’s Lic. #_______________________ State____________
RACE/ETHNICITY: Cauc. African American Asian/Pacific Isl. Hispanic Other (Identify)_________________________
Native American/Alaskan Native Tribe _____________________ Tribal / Member Number:_________________
Are you a US Citizen? Yes No Legal Resident? Yes No If “Yes”, Resident number _______________________
What languages do you speak? __________________________________ Occupation _________________________
Employer _____________________________ Address___________________________________________________
Work phone______________________ How long at current job
(If less than five years, please list employment history for past five years by attaching a separate sheet)
Do you have health insurance? Yes No If yes, Agency ______________________________________________
Would your health insurance cover an adopted child? Yes No

Residence: House Apartment Condo Mobile Home if mobile home, year built____________
Do you own your home or rent? Own Rent Other (specify) ___________________________________
Total square feet in residence How long at this residence?_______________________
Residence address _____________________________________________City _________________State__________
County ______________________ Residence phone ( ) Zip_____________
Mailing address (If different)____________________________________________City ________________ State__________
Please provide
Email detailed directions to your residence
_________________________________________ Zip______________
Cell phone ( )_____________________________ Cell phone ( )_________________________
(Applicant #1) (Applicant #2)

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List previous addresses for the past 10 years (Include City, State & Zip – use separate sheet if needed)
Check if for 1 Address FROM TO 5 Address FROM TO Check if for
Applicant Applicant
1 1 2
2
1 2 FROM TO 6 FROM TO 1 2
2

1 3 FROM TO 7 FROM TO 1 2
2

1 4 FROM TO 8 FROM TO 1 2
2

List ALL household members (In “Relationship to applicant” space list son, daughter, stepson etc.)
Social Birth Relationship to Name Social Birth Relationship to
Name security date Applicant security date Applicant
# #1 #2 # #1 #2
1 6

2 7

3 8

4 9

5 10

List extended family for Applicant #1 not living in the home (Include children, parents, brothers and sisters)
Name of extended family Age Relationship Occupation Address Phone with area code
1

List extended family for Applicant #2 not living in the home (Include children, parents, brothers and sisters)
Name of extended family Age Relationship Occupation Address Phone with area code
1

List household’s average monthly income ( list all sources of income & attach documentation of this income)
Applicant #1 Applicant #2
Gross monthly Net monthly Source Gross monthly Net monthly Source
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
Assets Checking $ Savings $ Checking $ Savings $

Stocks/bonds $ Real Estate $ Stocks/bonds $ Real Estate $

Trust $ Annuity $ Trust$ Annuity $
Other $ Type Other$ Type
Other $ Type Total combined monthly household income $

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Has Either applicant declared bankruptcy? Applicant #1 Yes No Applicant #2 Yes No

Location where order was filed________________________________________ Date__________________________
(Attach bankruptcy disposition court order)
Household expenses: Enter your household’s average monthly expenses (Do not include expenses that are deducted from paychecks)
House/Rent payments $ Child support payments $ Child care $
Utilities $ Loans outstanding $ Clothing $
Telephone $ Payments for other real estate $ Other $
Gasoline / Auto maintenance $ Recreation & entertainment $
Automobile payments $ Life insurance $
Automobile insurance $ Medical & dental insurance $
Groceries & household supplies $ Medical care (not covered by insurance) $ Total Monthly Expenses
Credit card payments $ Dental care (not covered by insurance) $ $

1. Have you ever applied to provide foster care? Applicant #1 Yes No Applicant #2 Yes No
Name of agency you applied with: ______________________________________________________ Date __________________________
Address of agency____________________________________________________________City________________________State___________
2. Have you ever applied for a childcare license? Applicant #1 Yes No Applicant #2 Yes No
Name of agency you applied with: _________________________________________________________ Date__________________________
Address of agency_____________________________________________________________City_______________________State__________
3. Have you ever applied to adopt a child? Applicant #1 Yes No Applicant #2 Yes No
Name of agency you applied with: ________________________________________________________ Date _________________________
Address of agency_____________________________________________________________City_______________________State__________
4. Have you ever applied for a license to provide care for adults or children? Applicant #1 Yes No Applicant #2 Yes No
Name of agency you applied with:_________________________________________________________ Date__________________________
Address of agency_____________________________________________________________City_______________________State__________

NOTE: Section 106 of the Federal Adoption and Safe Families Act: a record check revealing a felony conviction for child abuse/neglect, or
spousal abuse, or a crime against children (including child pornography), or a crime involving violence, including rape, sexual assault, or homicide, but
not including other physical assault or battery, and a court of competent jurisdiction has determined that the felony was committed at any time, such
final licensure approval shall not be granted; in any case in which a record check reveals a felony conviction for physical assault, battery or a drug-
related offense, and a court of competent jurisdiction has determined that the felony was committed within the past 5 years, such final licensure
approval shall not be granted.
A “YES”ANSWER TO ANY QUESTIONS BELOW REQUIRES ATTACHMENT OF A SEPARATE SHEET TO PROVIDE DETAILS
* SEE PAGE 5 FOR DETAILED INFORMATION REQUIRED
5. Has ANY household member been treated or is being treated for a psychological condition? (Use separate sheet if needed)
Person treated Condition or diagnosis Date Treatment end date Treating physician
diagnosed
Applicant # 1 Yes No
Applicant # 2 Yes No
Household member Yes No
Name:
6. Has ANY household member been prescribed medication for psychological/ mental health condition? (Use separate sheet if needed)
Person treated Medications Medications Length of time medication used Treating physician
Applicant # 1 Yes No
Applicant # 2 Yes No
Household member Yes No
Name:
7. Has ANY household member ever been arrested, convicted or currently facing charges, for ANY law enforcement
violation/offense? Applicant #1 Yes NO Applicant #2 Yes No Other household member Yes No Date______________________
Name____________________________________________ Name of arresting agency: _________________________________________
Agency address ___________________________________City County _________________ State______
7.a Is ANY household member currently or previously on parole or probation for an offense?
Applicant #1 Yes No Applicant #2 Yes No Other household member Yes No (Name)_______________________________________
Agency __________________________________________City County _________________State______
8. Was ANY household member ever investigated for child abuse or neglect by child protective services or law enforcement?
Applicant #1 Yes No Applicant #2 Yes No Other household member Yes No (Name)_________________________________
Name of investigating agency _______________________________________________ Date of investigation _________________
Agency address ____________________________________City County _________________State______
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 CAREGIVER APPLICATION UNITY #_________________

Residence floor plan (Please draw a floor plan, label the rooms and indicate square footage of each bedroom.)

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 CAREGIVER APPLICATION UNITY #_________________

References
Please list seven references that have known you for at least three years. No more than two of the seven may be relatives. Please
be sure to include name, full mailing address including zip code, telephone number, relationship and the number of years known.
1. Name Relationship Full Address Phone Number ( ) Years Known

Zip
2. Name Relationship Full Address Phone Number ( ) Years Known

Zip
3. Name Relationship Full Address Phone Number ( ) Years Known

Zip
4. Name Relationship Full Address Phone Number ( ) Years Known

Zip
5. Name Relationship Full Address Phone Number ( ) Years Known

Zip
6. Name Relationship Full Address Phone Number ( ) Years Known

Zip
7. Name Relationship Full Address Phone Number ( ) Years Known

Zip
Attachments to the application: As necessary attach copies of the following documents. Final disposition cannot be determined
until ALL required documents have been returned. (PLEASE check all attachments you have included.)
Social Security Card (s) Driver’s License (s) Automobile insurance Immigration card (s) if applicable
Documentation of monthly income, i.e., pay stubs, most recent tax return, or other. Marriage certificate if applicable
Divorce decree(s) if applicable Permits for well/septic systems if applicable Current immunizations for all pets
Bankruptcy disposition order, if applicable Employment history for past 5 years if applicable
Proof of TB testing for each applicant & household members 18 years of age or older
Recent photographs of all household members Photographs of all bodies of water on the property where you live
Proof of CPR training if applicable SAFE Questionnaire # 1 (completed) Homeowner’s insurance (if you own your home)
Renter’s insurance and landlord’s written permission for children to be in the home (If you rent your residence)
OTHER______________________________________________________________________________________________________
For any “YES” answer to QUESTIONS #5 THROUGH #8, an attachment is required as outlined below
Explanation/listing of medication *Attachment required. Provide history of illness causing use of medication and name
of attending physicain. Signed release of information from attending physician may be required.
Explanation/listing of psychiatric treatment/condition *Attachment required. If psychiatric condition is identified,
attending physian must provide written proof of ability to provide care. A Signed release of information from attending
physician may be required.

Criminal background/CPS history *Attachment required. Provide dates, circumstances and results of any CPS or
criminal investigation. List all charges, arrests, disposition of arrest, if on parole/probation, name of parole officer and
agency. Indicate all felony or misdemeanor arrests. Explain any child removed from your care or any termination of
parental rights vs. you/current or previous partner.
I/WE DECLARE that the information supplied in this application is complete and true. I/We understand that any incomplete or
false information WILL result in an immediate rejection of my/our application.
Signatures
Applicant #1 Date______________
Applicant #2______________________________________ Date______________

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 CAREGIVER APPLICATION UNITY #_________________

Office use only: Date received Office location: Agency

Assigned worker Date assigned______________ SAFE Q-1 returned Yes  No
Comments:
________________________________________________________________________________________________________

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 DIVISION OF CHILD AND FAMILY SERVICES
STATEMENT OF APPLICANT(S) RESPONSIBILITY

THIS IS AN AGREEMENT BETWEEN Division of Child and Family Services

(AGENCY) AND _____________________________________________________ (FOSTER/ADOPTIVE
CAREGIVERS(S)), FOR THE PROVISION OF FOSTER CARE SERVICES TO CHILD(REN) PLACED IN CARE.

I. Serve as an active member of the service delivery team.

The foster/adoptive caregiver(s) will:
1. Adhere to the Division’s policy on discipline as defined in the NAC regulation.
2. Participate in case planning conferences, team meetings, and foster care review board
meetings, if applicable.
3. Closely observe and document the foster child’s behavior so that it can be clearly and
specifically communicated to the service delivery team.
4. Inform the caseworker of any special needs of the child, including educational, treatment,
physical, etc.
5. Encourage the foster child to communicate with the caseworker.
6. Build a relationship with the primary family of the child to encourage that relationship and
facilitate reunification, if called for in the case plan.
7. Encourage visitation between the child and the primary family, if called for in the case plan.
8. Before requesting the removal of the child from the home, make every effort to maintain the
child’s current placement. Request an emergency team meeting regarding the requested
removal, if needed.
9. Respect the final decision made by the consensus of the service delivery team.

II. Meet the child’s basic daily needs.

The foster/adoptive caregiver(s) will:
1. Provide for the child: food, shelter, recreational opportunities, education as required,
maintenance of clothing, and transportation as defined in the case plan
2. Provide for the child: guidance, discipline, moral instruction, and/or opportunity for religious
practices and normally observed holidays and special occasions.
3. Instruct the child in good health and hygiene habits.
4. Respect each child as a unique individual and offer nurturing, loving care, which enhances
the child’s positive qualities.
5. Transport and accompany the child to medical and dental appointments.
6. Investigate and encourage the development of the child’s participation in community
activities.
7. Assist in preparing the child for transition to the primary family, adoptive family,
independent living, or other living arrangements.
8. Have a plan acceptable to the agency for the provision of care and supervision of the child by
a competent person whenever caregiver(s) is absent from the home.
9. Keep running notes and/or questions of important matters in order to have the most
productive discussions with the caseworker at monthly home visits.
10. Develop and maintain a lifebook for each foster child to chronicle their life while in
substitute care and ensure that it goes with the child to each placement.
III. Confidentiality
The foster/adoptive caregiver(s) will:
1. Respect the confidentiality or information concerning the child’s and/or his/her family’s
physical, mental, and social background, or the child’s past or present problems, and to share
this information only with appropriate persons specifically authorized by the agency.
2. Inform the child and primary family that information they give may need to be shared with
the caseworker, especially if the information could lead to harm to the child or others.

IV. Training
The foster/adoptive caregiver(s) will:
1. Complete all pre-service and in-service training as required for licensing.

V. Policies and Procedures

The foster/adoptive caregiver(s) will:
1. Be licensed in accordance with the rules of the Division of Child and Family Services, and
comply with all the rules.
2. Be aware and familiar with, adhere to and keep apprised of foster care regulations and
standards.
3. Give the agency adequate notice (i.e., five (5)) working days when requesting removal of a
child from the home, except where there is an immediate danger to the foster child or others
if the child is not removed.
4. Adhere to the Division’s policy on discipline as defined in the NAC regulations.

I (WE) HAVE READ AND AGREE WITH THE CONTENTS OF THIS DOCUMENT:

APPLICANT I DATE

APPLICANT II DATE

DIVISION REPRESENTATIVE DATE

 DIVISION OF CHILD AND FAMILY SERVICES
STATEMENT OF APPLICANT(S) AGREEMENT

I (We) agree the Division of Child and Family Services cannot issue a Foster Home License nor place
children with us without our agreement to the following conditions.

I (We) voluntarily agree:

1. To report to the Division any change of address before moving, sickness in the family or changes
in the family household and sickness of, or accident to, child or children placed with us.
2. To treat the child or children whom we may receive for Foster Care as members of our family.
3. To secure permission of the supervising agency before making plans for taking the child or
children out-of-state.
4. To carry out instructions of the supervising agency for care of the child and to cooperate with the
division in maintaining standards.
5. To allow the representative of the Division and/or supervising agency to visit this home. We
agree the Division and/or supervising agency may make unannounced home visits.
6. That the Division has the responsibility to make and carry out plans for the transfer of children
placed in our home to other homes, adoption, return to relatives or other disposition as may
appear to the Division to be for the best interest of any child placed with us. These transfer plans
will be discussed with us, along with our observations and recommendations, to assist the
Division to make the most appropriate plan for the child.
7. That the reasons for refusal to accept the placement of a child in our home cannot be based on
race, religion, ethnic origin or handicap.
8. To obtain any required training before licensure or re-licensure.
9. To maintain the child’s confidentiality per NAC 424.485.

The information given in our application is true and complete to the best of our knowledge. We each
have read and agree to comply with this statement of agreement and all other rules as set forth in the
Nevada Foster Care requirements (NAC 424), of which we have received a copy.

I (We) have received a signed copy of the statement of agreement for our records.

Applicant I Date

Applicant II Date

I have discussed this statement of agreement with each of the above applicant(s), as well as those
Nevada Foster Care Requirements for which clarification was requested.

Division Representative Date

APPLICANT COPY
 DIVISION OF CHILD AND FAMILY SERVICES
STATEMENT OF APPLICANT(S) UNDERSTANDING

I, ____________________________________ and I, ____________________________________

Understand the Division’s primary concern is to find the best possible home for each child, therefore:

1. An application for Adoption, Foster Care of ICPC does not guarantee an

approval for placement of a child. An approval or denial is based on
the suitability of the family for children for whom the Division as responsibility.

2. If my/our application is approved, I/we are not guaranteed the placement of a

child in my/our home.

2. I/We hereby certify the foregoing facts are true and accurate to the best of
my/our knowledge. I/We understand that any falsifying of information may
result in an immediate denial of this application.

APPLICANT I DATE

APPLICANT II DATE
Jim Gibbons STATE OF NEVADA Michael J. Willden
Governor Director
Department of Health and Human
Services

Diane J. Comeaux
Administrator

DEPARTMENT OF HEALTH AND HUMAN SERVICES

DIVISION OF CHILD AND FAMILY SERVICES

AUTHORIZATION BY APPLICANT(S) FOR RELEASE OF PROTECTED HEALTH

INFORMATION OR CONFIDENTIAL INFORMATION

REGARDING:

____________________________________
NAME SOCIAL SECURITY NUMBER

____________________________________
NAME SOCIAL SECURITY NUMBER

You are authorized by the undersigned to release to the Division of Child and Family Services, the information
including but not limited to that indicated below. This authorization constitutes a full and complete release
from any liability resulting from disclosure of such information. This authorization also permits release of
medical information under the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255) and
Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act amendments of
1974 (P.L. 93-282). A photocopy of this form shall be as valid as the original.

This authorization shall be in force and in effect until which time this authorization to use or disclose this
protected health/confidential information expires. This authorization shall be valid for one year from the date
signed, unless otherwise specified.

DATA REQUESTED:

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

____________________________________
SIGNATURE DATE

____________________________________
SIGNATURE DATE

Please return this request to: Division of Child and Family Services