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Become A Respite Care Provider

Questionnaire

If you live in Washington state or are planning to move to Washington and you're interested in becoming a foster or adoptive parent, please fill out the questionnaire below.

1. Have you ever been a foster parent?
Yes
No

2. If yes, what city and state were you licensed in?
City  
State

3. What ages of children would you be interested in providing care for?
Infancy - 3 years old
3 to 5 years old
5 to 10 years old
10 to 15 years old
15 to 18 years old
All of the above

4. What is your current age?
18-30
31-40
41-50
51-60
Over 60

5. Are you:
Female
Male

6. Your current marital status:
Single
Married
Widow
Divorced

7. Would you consider taking a child that (please mark all that apply):
May have been sexually abused
May have emotional problems
May have medical needs
May have behavioral problems

8. Do you have any special training (i.e. medical, psychological)?
Type of training

9. Would you be willing to participate in training to learn new parenting skills and knowledge?
Yes
No

10. Are you interested in learning more about becoming a foster parent?
Yes
No

11. Would you like this information to be given to a foster home licensor in your area and have that licensor call you with more information on becoming a foster parent?
Yes, please have a licensor call with more information regarding this valuable program.
No


Name
Address
City
County
(*County is required. If inquiry is from out of state, please select "Out-of-state" as the county.)
State
Zip
Phone (with area code)
Email address

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