Get MN DHS DHS-4258A-ENG 2021-2024

Clear Form Data FILLABLE FORM DHS-4258A-ENG Minnesota Adoption and Foster Care 3-10 Application Instructions To apply for a child foster care license and/or adoption study complete and send this form along with the child placing agency. licensing Agency type of application applying for l New application l Renewal/update type of child you are interested in l Male l Female l Either l Specific child l Foster/adopt l Foster l Treatment l Adopt Age Range l Sibling group of up to children For International adoption only indicate specific country or area requested Applicant Contact information Applicant 1 Name Last first middle E-mail address Former names Pager or cell phone number Work phone number Home address home phone number state city zip code directions to home from agency emergency contact relationship to you telephone number If no phone how can you be contacted Household Identifying information List all adults and children not including foster children living or working in the home if more than six people add another sheet Marital Status choose one N Never married M Married living with spouse S Separated married living apart L Legally separated D Divorced W Widowed Race choose all that apply N American Indian/ Alaska Native A Asian B Black or African American P Pacific Islander/ Native Hawaiian W White Name Last race languages spoken area of specialized education SSIS 170 birth date Hispanic l Yes l No ethnicity marital status tribal affiliation religion highest grade completed occupation number of hours of work week Page 1 Household member 1 Page 2 Home Description of home as it pertains to adoption or foster care of children* school district in which home is located Children placed in the home would attend the following schools elementary middle/junior high high school school transportation Does applicant home school If yes has applicant s home school plan been approved by the public school district Does any household member smoke in the house Are there pets in the home l Yes l No l Yes l No If so what type s of pet s Do any pets in the home pose safety concerns l Yes l No Do pets have current vaccinations Dwelling information Check all that apply l Own l Mobile home l Rent l Second floor l Bus l Other l Multi-unit l Above second floor l Single family house l Basement l Wood burning stove or fireplace Briefly describe home neighborhood. Include information regarding the type of community e*g* rural urban suburban industrial demographics and information regarding resources such as medical facilities churches shopping and recreational opportunities. For purposes of international adoption include description of the home and property. Sleeping arrangements Indicate where a foster or adopted child will sleep* Bedroom Floor/Level Occupants Type of bed s Crib Single Double Bunk if bunk indicate upper-U or lower-L* Page 3 Storage space for personal possessions Use only for child foster care Experience with foster care/adoption Has applicant s previously applied or worked with or currently working with another foster care/adoption agency agency s name address dates of involvement and outcome Explain If the residential business is childcare is the provider licensed l Yes l No If applicable describe impact of home business on foster/adoption plan Transportation Do you have a valid drivers license l Yes l No If you own vehicles Are there age appropriate infant care seats Do you have adequate insurance for all vehicles Do you have access to a city bus l Yes l No l Will Obtain l Yes l No If yes distance to nearest bus stop Describe alternative transportation plan if family does not own an operating vehicle or live on a bus line Are you able to transport children to appointments or school if needed l Yes l No If no what alternative transportation are you able to provide References - Required at initial application only 1.