Fillable ESTO Foster Care Packet 1 - Fillable 46 (Eastern Shawnee Tribe of Oklahoma)

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ESTO Foster Care Packet 1 - Fillable 46 (Eastern Shawnee Tribe of Oklahoma)

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BROWSE EASTERN SHAWNEE TRIBE OF OKLAHOMA (OK) FORMS

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EASTERN
SHAUTNEE
TRIBE
OF OKI.AHOMA
FOSTER
CARE
PACK
PACKET
ONE
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
Personal Applicant lnformation
Name:
Height:
Date
of
Birth:
Male/Female:
Weight:
Social Security No.
Address:
Mailing Address
(lf
Different):
County of Residence:
School
District:
Where are
you
currently employed:
Trade/Vo-Tech:
Full Time/Part Time:
Length of employment:
What
is
your
total
income
per
month?
5
Tribal Affiliation:
Revised 6/19/2013
Personal Applicant
lnformation
Place
of Birth:
Phone No.
_
Last
Grade
Completed:
_
What is the
curent condition ofyour health?
(Circleone)
EXCEIIENT GOOD FAIR POOR
Doyou have
anysignificant
health
problems?
Do
you
belon8 to a church or other religious
organization?
Name of church:
Levelof lnvolvement:
lf a foster child in
yourcare
were ofa different religion or denomination, how would
you
facilitate the
spiritual needs of the.hild?
Oo
you
actively
participate
in any other social organizations? Please list:
Have
you
ever been arrested?
(Cirale
one)
YES NO Date and location ofarrest:
lf
yes,
explanation of arrest:
Have
you
ever been convided
ofa crime? Yts No Date and location of crime:
lf
yes,
explanation ofconviction:
Has any other member ofthe
household
ever been arrested
for a Ielony?
(circle
one) YEs No
lf
yes,
explanation of arest:
ls there any history of
physiaal,
sexual, and or emotional abuse
in
your
lite? Please explain:
_
Describe
your
cultural
perspective
concerning Tribal customs and ceremonies:
Revised 6/19/2013 Personal Applicant lnformation
Number of Beds Approved:
Do
you
have any
pets?
lf
so,
how many?
What kind? lndoor
or outdoor?
What
activities or
hobbies do
you
enioy
in
your
spare time?
What would be
your
attitude toward accepting a child who has been the
victim
of sexual/physical
abuse?
Do
you
have any
preferences
regarding
the age,
gender
or background
of a foster/adoptive child?
Please explain:
Revised 6/19/2013 Personal Applicant lnformation
References
are
required for any
person
interested in
becoming
a Placement
Resource Home
for
the
Eastem
Shawnee Tribe of Oklahoma.
These
references
may be contacted by mail,
phone
or email and will be asked a series of
questions
regarding their knowledge of
your
family, character, etc.
A minimum of 6
references are required; only 2 of those
may
be
from relatives.
Adult children of the applicants
will be contacted but
may NOT
be
included in the
six
references.
-
E
7
r\-
,t
Revired 05-2012 References
REFERENCE INSTRUCTIONS
Reference Form
Name of applicant
I
Name of applicant
II, if
applicable
Please include name, address,
phone
number,
email and
relationship
of each
reference
provided.
Name:
Address:
Phone:
Email:
Relationship:
Name:
Address:
Phone:
Email:
Relationship:
Name:
Address:
Phone:
Email:
Relationship
Name:
Phone:
Email:
Relationship
Name:
Address:
Phone:
Email:
Relationship:
Name:
Address:
Phone:
Email:
Revised
05-20 I 2
Relationship:
References
Address:
Family Financial
Statement
FINANCIAL
STATEMENT
average monthly income
Applicant #1 Gross lncome:
Applicant #2 Gross lncome:
Other lncome
(child
support,
investments, retirement, etc.):
MONTHLY BUDGET
1. Housing
(_Rent_Own)
2. Utilities
3. Food
4.
Medical
(prescriptions,
doctor, dentist)
5. lnsurance
(life,
home,
auto, etc.)
6.
Vehicle(s)
7. Tax Exempt/Charita ble Contributions
8.
Day Care/School Expenses
9. Entertainment
10.
Clothing
11. Gasoline
12. Miscellaneous
13. Credit Card/lnstallment
14. Student Loan(s)
Total
We are
in
arrears/behind
on the
following
debts
(list
all):
s
5
s
s
s
s
s
s
(
5
s
S
S
s
S
s
s
Applicant #1 Applicant #2
:!
aa
RELEASE STATEMENT
l,
,
hereby
grant
full
permission
without recourse, for the use
and
release
of
information
as
necessary for
the
purposes
of checking
with DHS
(and
other state child
protection
agencies), Child
Welfare
Registry, and Criminal
lnvestitation
for the
purpose
of suitability
of
adoption/foster home
placement
of child(ren).
Date
witnessed by
Date
Revised
6/19/2013
Release
Statement
Signature of
Applicant
HOME STUDY APPTICANT
-
PHYSICAL EXAMINATION
REPORT
Address: Cou nty:
o
Convulsive Disorder
o
Tu
bercu
losis
o
Mental lllness
o
Venereal Disease
o Heart Disease
o
Recent Major lnjury
Recent Surgery
(Specify):
o
Complete Recovery
o
Pa rtial Recovery
o
Continued Care
Check to indicate
if
patient
is
subject to any of the
following
symptoms or conditions:
o Headaches
o
Orthopedic Handicap
o Fainting
o
Asthma, Severe
o Other
(Please
Specify):
PHYSICAL EXAMINATION
o
Vision
o
Heart
o
Hearing
o Lungs-
o
Blood Pressure
General
Physica I
Condition:
NOTE: This form may be sued by the
physician
in lieu of a narrative or other type report form.
Name:
_
Age:
_
Height:
_
Weight:
_
Health History:
(Check
to indicate history of any of the following)
over what
period
of time
have
you
known the
patient
professionally:
Physician
Address:
Attach laboratory reports, as indicated, for tuberculosis, urine, etc.
Current Medications:
Does
patient
have
any condition that
would impair
ability
to care for children?
lf
ye\.
P lease Specifv'
Fxdminalron Date:
_
Children
and
Family
Services Division
Sequoyah Memorial Office Building
P.O. Box 25352
Oklahoma City, OK73125
(4OS)
522-1487
o
Fax:
(405)
521-4373
o
www.okdhs.org
Request for Child Abuse
and Neglect lnformation System
Search
The attached form is completed to request
a search of the Child Abuse and Neglect
lnformation
System
(CANIS)
for
prospective
adoptive
parents.
The search and report
of
CANIS information is
provided
to assist
in
evaluating the safety of the
home in
which a child
is
placed.
To
allow a timely completed search, ensure:
all applicable information regarding the applicant is
provided,
including
all cunent
and former names used by the applicant;
information regarding
the stepparent
is
provided
when a stepparent is the
prospective
adoptive
parent.
A
search
report is not required for the
custodial
biological
parent;
the applicant has signed the form;
verification from a home study
provider
or adoption agency, or a copy of the
Petition
for Adoption is included;
official documentation
from United
States
Bureau
of Citizenship
and lmmigration
Services
is
provided
when
the
request is for
an intemational adoption; and
Please contact the Child Protective Services Unit of the Children and Family
Services
Division
of OKDHS at
405-521-2283 if
you
have
questions.
Please allow four weeks for completion of the search report.
a
EIIToFHUI'/IA ERVIC
ORI AHOI\TA
EXCELLTNCE
()ilxrs
.
the
form
and
verification
of
impending
adoption and other applicable documentation
is mailed to the address listed
on
page
tvvo of
Form
04AN028E,
Request for
Child
Abuse and Neglect lnformation System Search, or fax to 405-521-437
3.
I ililt ililt ililililil il lrilil!il
ilil ilt ililt t!ilt ilil ilil tilt ilil
Oklahoma Department of Human
Services
(OKDHS)
is requested to conduct
a Child
Abuse and Neglect lnformation System
search
for
the adoptive applicants
named
below.
Type
of
prospective
adoption:
Stepparent
Tribal
lnternational
Grandparent
Domestic infant
Other
Other relative
Domestic child
Adoptive applicant one
Unsworn declaration under
penalty
of
perjury
I certify that an adoption is being
pursued
through
attorney, or
,
child-placing agency, and the search
report is used for this
purpose
only. I further certify under
penalty
of
perjury
under the
laws
of
the
State of Oklahoma that the
foregoing is
true and correct to the best of
my
information and belief.
Adoptive applicant full name
Aliases, including maiden name, former married name, and all other names
Date of birth Social Security number Phone number
Current street address City State Zip
Years at current address Previous county of residence
Previous street address City
State
zip Dates resided
Previous street address City
State
zip
Dates resided
Previous street address City
State zip Dates resided
Revised
9-9-2010
Date
1
Request for Child Abuse
and
Neglect
Information System
Search
n
tr
n
Applicant
signature
ffi
ot( LAHOiIA
u\cILLtNct
(xtlts
04AN02BE (DCFS-125)
04AN028E
(DCFS-125)
Request For
Child Abuse
And
Neglect lnformation System Search
Adoptive applicant full name
Aliases, including maiden name, former married name,
and all other
names
Date of birth Social Security number Phone number
Current street address City State
zip
Years at current address
Previous
county of
residence
Previous street address City State
zip Dates resided
Previous street address City State
zip Dates resided
Previous street address City State
zip
Adoptive
applicant two
Unsworn declaration under
penalty
of
perjury
I
certify
that an adoption is
being
pursued
through
attorney,or-,child.placingagency,andthesearch
report
is
used
for this
purpose
only. I further certify under
penalty
of
perjury
under the
laws of the State of Oklahoma
that the foregoing is true and correct to the best of my
information and belief.
Applicant
signature
Date
Mail to: Oklahoma Department of Human Services
Children and Family Services Division
Child Abuse and Neglect lnformation System
P.O. Box 25352
Oklahoma
City, Oklahoma 73125
PIease
allow
four weeks for
processing
the search.
Verification of impending adoption must accompany this request.
This request will not be completed when required verifications are
not included.
2
Revised
9-9-2010
Dates resided
OKLAHOMA DEPARTMENT OF HUMAN SERYICES
Request
for
Background
Check
Print information clearly. lncomplete forms cannot be
processed.
Ensure a
fax
confirmation
is
received verifying that each
page
was successfully faxed.
Full legal name
Last name
First name
Middle Name
Other
names used including maiden,
when
applicable
Date of birth
Q
Male
Q
Female
City and state of birth
Race
Social
Security number
Driver license
(DL)
number
Current street
address
City
State ZIP code
Phone number
Marital Status
Spouse's
name, when applicable
Have
you
ever been convicted ofa crime?
Q
Yes
Q
No
lf
yes,
explain.
Authorization to
Release lnformation
t,
,
hereby
certifo
that I understand the
purpose
of this form and background check
and
grant permission,
without
recourse, for the use and release of
information as necessary
for
the
purpose
of a
criminal background check and
driving record. This
information cannot be released
for
any other
purpose
without my written
permission.
Signature
Date
Form 04AD003E v.4
10t11t2012
Page 1 of 4
Part A. Applicant lnformation
l\(llllt\(l
0l(l.lftt',
State DL issued
This section is completed by the
requesting authority.
This request
is
!
new
I
a follow-up to the electronic
fingerprint submission by a
vendor
!
a
follow-up
to
National Criminal lnformation Center
(NCIC)
check
completed by law enforcement
OKDHS requests
!
Emergency Child
Welfare Services foster care applicant
name search
tr
Child
Welfare
Services
adoptive, foster,
kinship, or
guardian
parent
E
Child Welfare Services
trial reunification
E
Child
Welfare Services volunteer
E
OKDHS
employee access
to national criminal
history records check results
!
Developmental
Disabilities Services
!
Aging Services
Em
ployment-related
requests
!
Laura Dester Children's
Center employee
!
Pauline
E. Mayer Shelter employee
tr
OKDHS
employment
tr
Child care
facility employment
Requests
from non-OKDHS
entities
!
lndian Child Welfare adoptive,
foster, or
guardianship
parent
!
Private adoption
with
payment
!
lnternational adoption
with
payment
Form
04AD003E
v.4 10t1112012
Page
2 of 4
Part B. Background
Check Purpose
Office, county, or other
location where results
are
to be sent such as OKDHS county location code
and section such as
foster care or adoptions,
private
agency name, or attorney office name.
Contact
person
name and identifying information such as OKDHS specialist,
private
agency,
attorney, licensed individual, or case
manager.
City
Phone number Fax number
I explained
the
purpose
of this
form
and the background
check to the applicant.
Requesting authority signature
Date
Form
04AD003E
v.4 10t11t2012
Page
3 of 4
Part C. Requesting Authority and Location
Physical address
State ZIP code
This
section
is
completed by the OKDHS Chald Welfare Services Background Checks Program
Unit.
National Criminal History Records
Search Results
Oklahoma State Bureau of lnvestigation
(OSBI)
fingerprint
search results
Federal Bureau of lnvestigation
(FBl)
search results
Oklahoma Sex Offender Registry search results
Name-based Criminal History Search Results
OSBI name search results
DPS search
results
Oklahoma Sex Offender
Registry
search results
Form 04AD003E v 4
10t1112012
Page 4
of4
Part D. Search Results
Oklahoma Department of Public Safety
(DPS)
search results
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p:irCt-i
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click to sign
signature
click to edit
Fingerprint request instructions:
lf
you
have internet access
you
may
do
what is
called the
live
scan.
lf not,
you
will have
to
go
down to the
local
Sheriff's Dept.
(Call
ahead to see what times
are
best)
and
you
can request
they
get
them
for
you
then
I will
send them
in for
you.
lf
you
choose to do the live scan, see below for instructions.
The fastest and easiest way,
is
this:
http ://www. identogo.com/
Selecting Oklahoma
On
Line Scheduling
Follow the Link
Enter First and
Last Name
Select the
Applicant Type DHS Employee
-
Access
and
Review
(See
Screen Shot Below)
Select an Appointment Time and
location
Once the
worker
completes the
fingerprinting
appointment,
he
or she
should come back to the office and enter a request to
OBI using
(see
below).
The TCN number which Morpho
gives
the individual should be entered on the form.
The link to the OBI Form is
https://lro.
prod.okd
hs. int/req uestinterna l.aspx
LIVE SCAN
PROCESS:
See screen shot below
E;4.Appllffii
s
l{*rooo
Applicant Type
Pt& #I h .E ffin O.p.ffi d ffi S.dB br ft h
yoo
rG
(&5F2r?35:i
.-rt-delBi6tu:-.
6!C&LE
f
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hM an,
8tu5&Cr rRWr SlAltffil
cffia&nraffictufB
(i
I
GO
Download
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ESTO Foster Care Packet 1 - Fillable 46 (Eastern Shawnee Tribe of Oklahoma)

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Completed 20 July 2020

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