Online Inquiry
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<ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_First_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Applicant 1-First Name</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_Last_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Applicant 1-Last Name</label><input name="CST_2" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_DOB_A"> <i class="fa fa-font"></i><label class="er_fld_label required">Applicant 1-Date of Birth</label><input name="CST_5" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_First_B"> <i class="fa fa-font"></i><label class="er_fld_label">Applicant 2-First Name</label><input name="CST_3" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_Last_B"> <i class="fa fa-font"></i><label class="er_fld_label">Applicant 2-Last Name</label><input name="CST_4" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_DOB_B"> <i class="fa fa-font"></i><label class="er_fld_label">Applicant 2-Date of Birth</label><input name="CST_6" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Address_Street_1"> <i class="fa fa-font"></i><label class="er_fld_label required">Home Address Line 1</label><input name="CST_7" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Address_Street_2"> <i class="fa fa-font"></i><label class="er_fld_label">Home Address Line 2</label><input name="CST_8" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Address_City"> <i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_9" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Address_State"> <i class="fa fa-font"></i><label class="er_fld_label required">State</label><input name="CST_10" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Address_Zip"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code</label><input name="CST_11" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">What is your preferred method of contact? </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_12" value="Phone">Phone</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_12" value="Email">Email</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_12" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_12_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Phone_Home"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone Number</label><input name="CST_15" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_EMail"> <i class="fa fa-font"></i><label class="er_fld_label required">Email</label><input name="CST_16" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false" map_to="FH_Inquiry_How_Referred"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">How did you hear about us? </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_18" value="Facebook">Facebook</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_18" value="Instagram">Instagram</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_18" value="Flyer">Flyer</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_18" value="Friend">Friend</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_18" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_18_Other" type="text"></label></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Inquiry_How_Referred"> <i class="fa fa-font"></i><label class="er_fld_label">Who can we thank for referring you to our agency? </label><input name="CST_19" type="text"></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Have you ever been a foster parent before? </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_20" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_20" value="No">No</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_20" value="Relative Placement Only">Relative Placement Only</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_20" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_20_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">If you have fostered before, please provide details below: </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Agency</label><input name="CST_21" type="text" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Start Date</label><input name="CST_22" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">End Date</label><input name="CST_23" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Reason for leaving/transferring</label><textarea name="CST_25" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">Have you ever had any allegations/investigations while fostering? </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_26" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_26" value="Other:">Other:<input class="cst_Other" name="CST_26_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">If yes, please provide details below: </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date</label><input name="CST_27" type="text" class="er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Allegation & Outcome</label><textarea name="CST_29" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Date</label><input name="CST_30" type="text" class="er_fld_width25"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Allegation & Outcome</label><textarea name="CST_31" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;" map_to="FH_Inquiry_Why_Parents"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Why are you interested in fostering youth? </label><textarea name="CST_32" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Do you own or rent your home?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Own">Own</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Rent">Rent</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_34" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_34_Other" type="text"></label></li><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Type of residence</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_33" value="Single Family Home">Single Family Home</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_33" value="Apartment">Apartment</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_33" value="Condo">Condo</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_33" value="Townhome">Townhome</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_33" value="Manufactured Home">Manufactured Home</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_33" value="Duplex/Triplex">Duplex/Triplex</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_33" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_33_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false" map_to="FH_NumBedrooms"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">How many bedrooms are in your home? </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="1">1</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="2">2</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="3">3</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="4">4</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="5">5</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="6">6</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_35" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_35_Other" type="text"></label></li><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">If you decide to foster, how many bedrooms would be available for foster youth? </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="1">1</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="2">2</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="3">3</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="4">4</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="5">5</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="6">6</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_36" value="Master bedroom- Infants only (2 max)">Master bedroom- Infants only (2 max)</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_36" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_36_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">How many children would you like to foster? </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_48" value="1">1</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_48" value="2">2</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_48" value="3">3</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_48" value="4">4</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_48" value="5">5</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_48" value="6">6</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_48" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_48_Other" type="text"></label></li><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Preferred Ages</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_49" value="Infants Only">Infants Only</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_49" value="0-3">0-3</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_49" value="4-8">4-8</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_49" value="9-12">9-12</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_49" value="13-16">13-16</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_49" value="16-18">16-18</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_49" value="18+">18+</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_49" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_49_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Preferred Gender(s)</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_50" value="Male">Male</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_50" value="Female">Female</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_50" value="No Preference">No Preference</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_50" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_50_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Please list all person(s) occupying bedrooms and their date of birth/age: </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Master Bedroom</label><input name="CST_39" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">DOB/Age(s)</label><input name="CST_40" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Bedroom 2</label><input name="CST_37" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">DOB/Age(s)</label><input name="CST_38" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Bedroom 3</label><input name="CST_41" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">DOB/Age(s)</label><input name="CST_42" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Bedroom 4</label><input name="CST_43" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">DOB/Age(s)</label><input name="CST_44" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Bedroom 5</label><input name="CST_45" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">DOB/Age(s)</label><input name="CST_46" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">What is your primary source of income? </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_51" value="Employer">Employer</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_51" value="Self-Employed">Self-Employed</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_51" value="Combat Pay">Combat Pay</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_51" value="Disability Benefits">Disability Benefits</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_51" value="Social Security">Social Security</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_51" value="Unemployment">Unemployment</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_51" value="Child Support">Child Support</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_51" value="Alimony">Alimony</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_51" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_51_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Employment Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Applicant 1- Employer</label><input name="CST_52" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Applicant 1-Type of work</label><input name="CST_53" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Applicant 2-Employer</label><input name="CST_54" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Applicant 2- Type of work</label><input name="CST_55" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Make and Model of Vehicle </label><input name="CST_56" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Number of passengers (not including the driver)</label><input name="CST_57" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Does anyone in the home smoke?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_58" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_58" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_58" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_58_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Do you operate a day care facility? </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_59" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_59" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_59" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_59_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">If you operate a day care facility, what is your current license number and capacity? </label><input name="CST_60" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Is there a pool or spa at your home? </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_61" value="In Ground Pool">In Ground Pool</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_61" value="Above Ground Pool">Above Ground Pool</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_61" value="In Ground Spa">In Ground Spa</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_61" value="Above Ground Spa">Above Ground Spa</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_61" value="None">None</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_61" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_61_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">If yes, please tell us about the safety features of your pool/spa</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="Gated">Gated</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="Locking Cover">Locking Cover</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_62" value="Safety Net">Safety Net</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_62" value="Other:">Other:<input class="cst_Other" name="CST_62_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Do you have any pets? </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_63" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_63" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_63" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_63_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">If yes, what kind of pet(s)? </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_64" value="Dog">Dog</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_64" value="Cat">Cat</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_64" value="Bird">Bird</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other" type="checkbox" name="CST_64" value="Other:">Other:<input class="cst_Other" name="CST_64_Other" type="text"></label></li><li class="er_fld_type_checkbox er_fld_type_radio_col2" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label">How many pets? </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_66" value="1">1</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_66" value="2">2</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_66" value="3">3</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_66" value="4">4</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_66" value="5">5</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_66" value="6">6</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other" type="checkbox" name="CST_66" value="Other:">Other:<input class="cst_Other" name="CST_66_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 100%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">These questions apply to members of the household over the age of 18....</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Has anyone lived outside of California in the past 5 years? </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_67" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_67" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_67" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_67_Other" type="text"></label></li><li class="er_fld_type_checkbox" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Does anyone have a criminal record? </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_68" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_68" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_68" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_68_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If yes, please provide details (date, type of offense):</label><textarea name="CST_69" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Does anyone have any unpaid traffic tickets? </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_70" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_70" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_70" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_70_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If yes, please provide details (date, type of offense):</label><textarea name="CST_71" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Has CPS or the police ever been called to your home? </label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_72" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_72" value="No">No</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_72" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_72_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">If yes, please provide details (date, type of offense):</label><textarea name="CST_73" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section sortable-chosen" draggable="true" style="width: 50%;"><i class="fa fa-header"></i><label>**FOR RELATIVE PLACEMENTS ONLY**</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">If you are seeking Resource Family Approval for the placement of a relative please note, the placing agency (THE COUNTY) has the final authority over the decision to place children with relatives and the agency is unable to overturn that decision. The agency must verify the county's intent to place the minor with a relative before approving for RFA. Please provide the following information: </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Child's Name and Date of Birth</label><input name="CST_76" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">County Social Worker's Name:</label><input name="CST_77" type="text"></li><li class="er_fld_type_text er_fld_selected" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">County Social Worker's Phone or Email: </label><input name="CST_78" type="text"></li></ul><ul class="er_fld_row" id="er_row_last"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 100%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Training is available Monday through Friday between 8:30 a.m. and 3:00 p.m., which days work best for you with this schedule in mind? </label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_74" value="Monday">Monday</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_74" value="Tuesday">Tuesday</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_74" value="Wednesday">Wednesday</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_74" value="Thursday">Thursday</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_74" value="Friday">Friday</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_74" value="A.M.">A.M.</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_74" value="P.M.">P.M.</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_74" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_74_Other" type="text"></label></li></ul>
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