General Information
In which Foster Care Initiative role are you currently interested in participating?
Foster FamilyRespite FamilySupporting Mentor
Phone Email
Date Of Birth
Current Address
City State Zip
MaleFemale MarriedSingle Spouse's Name
Anniversary Date Number of Children
Current employer Occupation
Name and Ages of Children
Name Age
Do you currently have anyone (other than children listed above) living in your household that is over the age of 18? If so, please list their name, age, and relationship to you.
Name Age Relationship
All-In for Jesus
Have you gone all in for Jesus? YesNo
Have you been water baptized? YesNo
Please explain briefly your experience when you went all-in for Jesus
Please describe your relationship with Jesus at this time in your life
Do you regularly attend Community Church? YesNo How long have you attended?
Which Campus Western BranchKempsville
Do you tithe on regular basis to Community Church? YesNo
Are you in a Community Group? YesNo
How long have you been attending group?
Group Leader Name
Are you on a serve team? YesNo
Which team?
Have you ever served on any other teams? YesNo
Which Teams?
Church Background
List below other churches you have attended regularly during the last five years
Church #1 Name
Dates Attended Pastor Name
City State Zip
Church #2 Name
Dates Attended Pastor Name
City State Zip
Church #3 Name
Dates Attended Pastor Name
City State Zip
Foster Care Initiative Information
How did you find out about the Foster Care Initiative?
Please share why you want to be a part of this initiative.
Have you ever been a foster (resource) parent before?
If so, through what agency or County DFCS were you approved?
If you want to be a supporting mentor or respite family, when would you be available to support foster children and their foster family? (check all that apply)
If applicable, please describe any obstacles or potential obstacles we might need to be aware of regarding your family’s desire to participate in this initiative (travel, other commitments, medical conditions, etc.).
Lifestyle Information:
Have you ever been accused or convicted of any form of a crime or abuse? YesNo
If yes, please explain
Do you currently use illegal drugs? YesNo
Do you have a history of either physical or sexual abuse as a victim or abuser? YesNo
If yes, please explain
Have you been involved in homosexual activity within the last five years? YesNo
Do you presently have any communicable diseases? YesNo
Do you currently view pornography? YesNo
Are you living with someone of the opposite sex other than a spouse or family member? YesNo
Do you currently use tobacco? YesNo
Do you currently consume alcohol? YesNo
If yes, please explain
Signature: By typing my name and the date, I am certifying that the information contained on this application is correct to the best of my knowledge.
Signed: Date: