Please let us know how we may serve you
Name:
Address:
City:
Zip:
County:
Home Phone:
Work:
Alternative Phone:
Email Address:
Are you 21 years of age or older? Yes
No
Do you have a spouse/partner? Yes
No
Name:
Do you have children living in the home? If yes, what are their names and ages?
Boy(s) Name(s)
Boy(s) Age(s)
Girl(s) Name(s)
Girl(s) Age(s)
Does anyone else live in the home? Yes
No
Gender
Age
How many bedrooms in your home?
Check the age, gender and race of children you prefer. (Check all that apply)
AGE
GENDER
RACE
0-4
Male
Black/African American
5-8
Female
Asian
9-12
Any of the above
Whote/Caucasian
13-19
Hispanic
Any of the above
Native American
Other
Any of the above
How did you hear about Our Children's Keeper? (Check one and provide name)
Family/Friend
Foster Parent
Name
Community Event
Publications
Name
Billboard Advertisement
Penny Saver
Internet
Other
Please check box if you would like to schedule an orientation