Surname:

First names:

Previous Names:

Date of Birth:

Place of Birth:

Nationality:

If not a British citizen, do you have indefinite leave to remain in the UK?

Yes
No

Ethnic Origin:

Religion:

Languages Spoken:

Marital Status:

Occupation:

Home Telephone No:

Mobile Phone No:

Email Address:

Your Local Authority:

Address:

YOUR CURRENT EMPLOYMENT (if applicable)

Name of employer:

Address:

Telephone No:

Date commenced:

Job Title:

Full time /Part Time:

OTHER DETAILS

Do you currently have a Full UK driving licence?

Yes
No

Do you have a family car?

Yes
No

Do you have any personal experience of fostering?

Yes
No

If yes please describe what type of experience:

YOUR LIVING ARRANGEMENT

Type of property (Tick one box only):

Flat
Terraced
Semi-Detached
Detached
Maisonette
Town-house
Bungalow

Other:

Occupation Terms (Tick one box only):

Private rented
Council rented
Housing Association rented
Owned/Mortgaged
Owned outright

Other:

If rented, do you have security of tenure for at least 2 years?

Yes
No

If No, please explain:

Number of Bedrooms: (Tick one box only)

1
2
3
4
5
6

Other:

Do you have a garden?

Yes
No

Do you have wheelchair access?

Yes
No

YOUR LOCAL AREA

Please provide details of how close the following amenities are to your current address.
e.g. 10 minute walking or 20 minutes by car.

Playgroup:

Nursery School:

Primary School:

Secondary School:

General Practitioner:

Optician:

Dentist:

Shops/High Street:

Hospital:

Play Area:

Community Centre:

YOUR FAMILY

Please provide details of any children that currently live with you and if applicable any children you childmind.

Number of children living in the house? (Tick one box only):

1
2
3
4
5
6

Other:

Number of children that have previously lived with you but now live independently? (Tick one box only):

1
2
3
4
5
6

Other:

Number of any other people living in your current accommodation who have not already been mentioned in this form? (Tick one box only):

1
2
3
4
5
6

Other:

YOUR HEALTH

Do you have any serious illnesses?

Yes
No

If yes please give details including medication/treatment used:

Do you have any minor illnesses that require regular medication?

Yes
No

If yes please give details including medication/treatment used:

Have you had any major/minor surgery during the last five
years?

Yes
No

If yes please give details:

Have you ever experienced any mental health problems?

Yes
No

If yes please give details:

Please provide details of any medication used by you not already mentioned

FOSTERING

What age group of children/young people do you wish to care for? (Tick all boxes that apply):

0 - 5
6 - 11
12 - 18
All Ages

Which gender of children/young people do you wish to care for? (Tick one box only):

Male
Female
Both
Depends on age

What type of care do you wish to provide? (Tick all boxes that apply):

Short Term
Long Term
Respite Care
Emergency Placements
Remand Placements
Any

Would you consider caring for a family of children?

Yes
No

If yes please state maximum number

Would you consider caring for children with any of the following
disabilities? (Tick all one boxes that applyonly):

Physical Disability
Learning Disability
Sensory Disability
None of these

YOU AND FOSTERING

Where did you hear about Black Foster Care

Are you, or have you ever been, a registered foster carer with any
Local Authority or with any Independent Fostering Agency?

Yes
No

If yes please give details

Are you or have you ever been a registered childminder?

Yes
No

If yes please give details

Why do you wish to foster children and/or young people?

Before foster placements can be offered to you, you will need to
undergo a detailed assessment, and will need to attend a number
of short courses. Are you willing to do this?

If you work, are you willing to reduce your working hours to
provide appropriate care to children placed with you?

CRIMINAL CAUTIONS AND CONVICTIONS

Pleased prvide details below if either of the applicants has ever received a caution or a criminal conviction. Black FosterCare.co.uk are required by law to make a criminal convictions check on all adult members of your household, before you can be registered as a foster carer. We will also carryout a criminal records check on any adult who is a very regular visitor to your home and who is likely to have contact with any foster child.

Date of Offence(s):

Conviction/Caution details:

Please do the same for other members of your household.

Name of offender /Date of offence::

Conviction / Caution details:

SECOND APPLICANT

Surname:

First names:

Previous Names:

Date of Birth:

Place of Birth:

Nationality:

If not a British citizen, do you have indefinite leave to remain in the UK?

Yes
No

Ethnic Origin:

Religion:

Languages Spoken:

Marital Status:

Occupation:

Home Telephone No:

Mobile Phone No:

Email Address:

Your Local Authority:

Address:

YOUR CURRENT EMPLOYMENT (if applicable)

Name of employer:

Address:

Telephone No:

Date commenced:

Job Title:

Full time /Part Time:

OTHER DETAILS

Do you currently have a Full UK driving licence?

Yes
No

Do you have a family car?

Yes
No

Do you have any personal experience of fostering?

Yes
No

If yes please describe what type of experience:

YOUR LIVING ARRANGEMENT

Type of property (Tick one box only):

Flat
Terraced
Semi-Detached
Detached
Maisonette
Town-house
Bungalow

Other:

Occupation Terms (Tick one box only):

Private rented
Council rented
Housing Association rented
Owned/Mortgage
Owned outright

Other:

If rented, do you have security of tenure for at least 2 years?

Yes
No

If No, please explain:

Number of Bedrooms (Tick one box only):

1
2
3
4
5
6

Other:

Do you have a garden?

Yes
No

Do you have wheelchair access?

Yes
No

YOUR LOCAL AREA

Please provide details of how close the following amenities are to your current address.
e.g. 10 minute walking or 20 minutes by car.

Playgroup:

Nursery School:

Primary School:

Secondary School:

General Practitioner:

Optician:

Dentist:

Shops/High Street:

Hospital:

Play Area:

Community Centre:

YOUR FAMILY

Please provide details of ANY children that currently live with you and if applicable any children you childmind.

Number of children living in the house? (Tick one box only):

1
2
3
4
5
6

Other:

Number of children that have previously lived with you but now live independently? (Tick one box only):

1
2
3
4
5
6

Other:

Number of any other people living in your current accommodation who have not already been mentioned in this form? (Tick one box only):

1
2
3
4
5
6

Other:

YOUR HEALTH

Do you have any serious illnesses?

Yes
No

If yes please give details including medication/treatment used:

Do you have any minor illnesses that require regular medication?

Yes
No

If yes please give details including medication/treatment used:

Have you had any major/minor surgery during the last five
years?

Yes
No

If yes please give details:

Have you ever experienced any mental health problems?

Yes
No

If yes please give details:

Please provide details of any medication used by you not already mentioned

FOSTERING

What age group of children/young people do you wish to care for? (Tick all boxes that apply):

0 - 5
6 - 11
12 - 18
All Ages

Which gender of children/young people do you wish to care for? (TIck one box only):

Male
Female
Both
Depends on age

What type of care do you wish to provide? (Tick all boxes that apply):

Short Term
Long Term
Respite Care
Emergency Placements
Remand Placements
Any

Would you consider caring for a family of children?

Yes
No

If yes please state maximum number

Would you consider caring for children with any of the following
disabilities? (Tick all boxes that apply):

Physical Disability
Learning Disability
Sensory Disability
None of these

YOU AND FOSTERING

Where did you hear about Black Foster Care

Are you, or have you ever been, a registered foster carer with any
Local Authority or with any Independent Fostering Agency?

Yes
No

If yes please give details

Are you or have you ever been a registered childminder?

Yes
No

If yes please give details

Why do you wish to foster children and/or young people?

Before foster placements can be offered to you, you will need to
undergo a detailed assessment, and will need to attend a number
of short courses. Are you willing to do this?

Yes
No

If you work, are you willing to reduce your working hours to
provide appropriate care to children placed with you?

Yes
No

CRIMINAL CAUTIONS AND CONVICTIONS

Pleased prvide details below if either of the applicants has ever received a caution or a criminal conviction. Black FosterCare.co.uk are required by law to make a criminal convictions check on all adult members of your household, before you can be registered as a foster carer. We will also carryout a criminal records check on any adult who is a very regular visitor to your home and who is likely to have contact with any foster child.

Date of Offence(s):

Conviction/Caution details:

Please do the same for other members of your household.

Name of offender /Date of offence::

Conviction / Caution details: