Children and Young People's Services

Have your own children been ‘looked after’ by the Local Authority?

Yes

No

Has there been any bereavement in the family within the last year?

Yes

No

Has there been a recent or planned house move?

Yes

No

Have you or your partner had any serious health concerns within the last year?

Yes

No

Do you or your partner have any serious criminal convictions that would cause concern in caring for children?

Yes

No

Are there 3 or more dogs in the house?

Yes

No

Is the main carer a child minder?

Yes

No

Name:

Date of Birth:

Full Address:

Telephone Number:

Any Previous Names:

Gender:

Male Female

Ethnicity:

(Please select) Asian/British - Bangladeshi Asian/British - Indian Asian/British - Pakistani Asian/British - Other Asian Black/British - African Black/British - Caribbean Black/British - Other Black Chinese Declined to Say Mixed/White - Black African Mixed/White - Asian Mixed/White - Black Caribbean Mixed - Other Other Ethnic Group White Other White British White Irish

Religion:
If Other Religion, please give details

(Please select) Buddhist Christian Gujarati Declines to disclose religion Hindu Jehovah Witness Jewish Muslim No Religion Roman Catholic Sikh Toaist

First Language:

If your first language is not English, please specify whether you also speak English

Yes I speak English

Occupation:

Hours of Work:

Name and Address of GP:

Do you consider yourself to be disabled?

Yes No

If yes, please give details of disability:

Name:

Date of Birth:

Full Address:

Telephone Number:

Any Previous Names:

Gender:

Male Female

Ethnicity:

(Please select) Asian/British - Bangladeshi Asian/British - Indian Asian/British - Pakistani Asian/British - Other Asian Black/British - African Black/British - Caribbean Black/British - Other Black Chinese Declined to Say Mixed/White - Black African Mixed/White - Asian Mixed/White - Black Caribbean Mixed - Other Other Ethnic Group White Other White British White Irish

Religion:
If Other Religion, please give details

(Please select) Buddhist Christian Gujarati Declines to disclose religion Hindu Jehovah Witness Jewish Muslim No Religion Roman Catholic Sikh Toaist

First Language:

If your first language is not English, please specify whether you also speak English

Yes I speak English

Occupation:

Hours of Work:

Name and Address of GP:

Do you consider yourself to be disabled?

Yes No

If yes, please give details of disability:

Number of children, please provide names and date of birth

Which type of fostering are you interested in?

Long-term
Short-term
Respite/Emergency
Any

Which gender child would you like to be considered for?

Male
Female
Either

How many children would you like to be considered for?

1
2
3

Which age ranges would you like to be considered for?
(you can select more than one option)

0 - 2
2 - 4
4 - 6
6 - 8
8 - 10
10 - 12
12 - 14
14 - 16

Will there be one carer available at all times for children in care?

Yes No

If you are a couple, have you been married or cohabiting for at least 2 years?

Yes No

Do you have a telephone?

Yes No

Do you have a spare bedroom?

Yes No