1.formal Application

Formal Application Instructions
1. Please fill out ALL information.
2. Under ‘Employment information’ please make sure to include your

supervisor’s name, the name of the company, and the full address (street
number, name, city, state, and zip code).
a. Please make your employer aware that Bethany Christian Services will
be sending them a reference form via mail, so they are expecting it.
3. Under ‘Personal References’ please note that each reference will be mailed a
reference form to fill out. Therefore, please fill out the full address for each
reference (street number, name, city, state, and zip code). Please double
check that the email and phone number are correct for each reference
a. Please make your personal references aware that Bethany Christian
Services will be sending them a reference form via mail, so they are
expecting it.
4. Please note that if any information is missing, the application will be

returned for corrections, and this will delay your approval process.
Page 1 of 8
Bethany Christian Services
Foster/Adoption Formal Application
Transitional Foster Care [ ]Foster Care [ ] Respite [ ]
APPLICANT 1 APPLICANT 2
Name
Name: kirsy E. Jimenez
:
First Middle Last First Middle Last
Maiden Name: 3054149409 Maiden Name:
Cell Phone: Cell Phone:

Soc. Sec. # 135 25 8321 Soc. Sec. #
Date of Birth: 12-08-1987 Date of Birth
Place of Birth: US citizen Place of Birth:
Citizenship: Citizenship
Race: hispano Race:
Hobbies/Interest: cook, art Hobbies/Interest:
Community Activities: Community Activities:
Medical issues you are Medical issues you are

being treated for: no being treated for:
Physician & Phone No.: Physician & Phone No.:
Have you ever filed Have you ever filed

bankruptcy?:
no bankruptcy?:
Last School attended/ Last School attended/
Highest Degree: Highest Degree:
Marital Status: married Marital Status:
If Married, If Married,
Date & Place: Date & Place:
Previous Marriage(s): Previous Marriage(s):
Yes / No Yes / No
Date of Marriage(s): Date of Marriage(s):
Date Terminated: Date Terminated:
How Terminated: How Terminated:

Have you ever been Have you ever been
arrested: If yes, explain arrested: If yes, explain
Military Service: Military Service:
Branch, Dates/Years & Branch, Dates/Years
Type of Discharge: & Type of Discharge:
CURRENT RESIDENCE
Street Address: Home Phone:
City/State/Zip: Primary Email:
County:
Previous Residence (past

10 year):
Page 2 of 8
CRIMINAL HISTORY
Have you or any member of your household ever been arrested for a misdemeanor or
felony charge (Yes/No)?
Warning: Information about expunged arrests/convictions may be disclosed by law enforcement.
Do you or any member of your household have any criminal (misdemeanor or felony)
convictions (Yes/No)?
If Yes, please list type of conviction, the year in which it occurred and the circumstances
below (add additional pages if necessary) :
Type of Conviction Year Location Circumstances
EMPLOYMENT HISTORY
Applicant One Employment Information

(Please list most recent employment first):
Supervisor and Phone Job Title/Dates Annual

Employer, Address, and Schedule
Number of Employment Income
Applicant Two Employment Information

(Please list most recent employment first):
Supervisor and Job Title/Dates Annual

Employer, Address, and Schedule
Phone Number of Employment Income
Page 3 of 8
PARENTING INFORMATION
What is the sleeping arrangement for the child(ren) you plan to care for? Please note
that state regulations require that each child have his/her own bed and that no child 5 or
older may be in a bedroom with a child of the opposite sex.
Please Check ALL child demographics you are open to accepting in your home
__American Indian/Native Alaskan Ethnicity Age Range
__Black/African American __Hispanic Between ____ and ____ y/old
__Native Hawaiian/Pacific Islander __Non-Hispanic
__Asian Gender Amount children willing to take
__White __Male Maximum Number of Children____
__Other/undetermined __Female Maximum Number of Siblings____
People living in household and/or dependents
Name Gender Date of Birth Relationship
Does anyone living in your home have special needs? Please explain.
Are you open to children with the following placement needs?

Emotional Impairment: Yes / No
Medical Concerns: Yes / No
Physical Challenges: Yes / No
Mental/Cognitive Impairment: Yes / No
Page 4 of 8
What experience do you have with special needs children, as listed above?
Do you have any experience working with emotionally impaired or sexually abused
children (Yes/No)? If Yes, please explain:
Please explain why you would like to be a Foster Parent?
Other Agency Involvement
Have you ever applied or acted as a foster or adoptive parent with another agency? If
yes, please list agencies you have worked with or are currently working with.
Agency: Contact Person:
Address:
Phone #: Email Address:
Dates you were licensed with agency:
Have you, or a member of your household, ever received counseling or

treatment including medication, and/or hospitalization for any of the following?
If yes, please explain:
Emotional/Mental Health
Yes / No
Concerns:
Medical Concerns: Yes / No
Marital Concerns: Yes / No
Alcohol Use: Yes / No
Page 5 of 8
Other Drug Use: Yes / No
Other (Please explain): Yes / No
Your worker may request that you sign a release of information for your records or for further
assessment.
PERSONAL REFERENCES
Please list references who know both applicants well.
By including their names, you are giving the agency permission

to contact the following references by phone, letter or in person.
Name Relationship Add./City/State/Zip Phone/Email

1.
2.
3.
4.
Church & Pastoral Reference
If you are not currently a member of a church, please provide information for an additional personal reference.
Church Name & Address/

Pastor Phone/Email
Denomination City/State/Zip
PAST COUNTIES LIVED IN

Please list all COUNTIES you have lived in for the past 10 years
COUNTY DATES LIVED THERE
APPLICANT 1
Page 6 of 8
COUNTY DATES LIVED THERE
APPLICANT 2
PAST STATES LIVED IN

Please list all STATES you have lived in for the past 5 years
STATE DATES LIVED THERE
APPLICANT 1
STATE DATES LIVED THERE
APPLICANT 2
Final Comments: Use this space to include any additional comments you feel are relative
to your application process.
I (we) have completed this form to the best of my (our) knowledge. I (we) declare that all
information given here is true and may be verified by an agency representative.
I (we) understand that approval of my (our) home study is the decision of Bethany Christian
Services. I (we) agree to inform Bethany of any changes in our family composition and changes in
our living situation, employment, health, or other significant changes.
Signature of Applicant One Date Signature of Applicant Two Date
Page 7 of 8
Page 8 of 8

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Formal Application Instructions

1. Please fill out ALL information.

2. Under ‘Employment information’ please make sure to include your

4. Please note that if any information is missing, the application will be

Cell Phone: Cell Phone:

Community Activities: Community Activities:

Medical issues you are Medical issues you are

Physician & Phone No.: Physician & Phone No.:

Have you ever filed Have you ever filed

Date of Marriage(s): Date of Marriage(s):

Date Terminated: Date Terminated:

How Terminated: How Terminated:

City/State/Zip: Primary Email:

Previous Residence (past

Warning: Information about expunged arrests/convictions may be disclosed by law enforcement.

Applicant One Employment Information

Supervisor and Phone Job Title/Dates Annual

Applicant Two Employment Information

Supervisor and Job Title/Dates Annual

People living in household and/or dependents

Name Gender Date of Birth Relationship

Are you open to children with the following placement needs?

Please explain why you would like to be a Foster Parent?

Other Agency Involvement

Agency: Contact Person:

Phone #: Email Address:

Dates you were licensed with agency:

Have you, or a member of your household, ever received counseling or

If yes, please explain:

Medical Concerns: Yes / No

Marital Concerns: Yes / No

Alcohol Use: Yes / No

Other (Please explain): Yes / No

By including their names, you are giving the agency permission

Name Relationship Add./City/State/Zip Phone/Email

Church & Pastoral Reference

Church Name & Address/

PAST COUNTIES LIVED IN

PAST STATES LIVED IN

STATE DATES LIVED THERE

Signature of Applicant One Date Signature of Applicant Two Date

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