Form Rfa 00 - Conversion To Resource Family - Release Of Information
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1State of California – Health and Human Services Agency
California Department of Social Services
CONVERSION TO RESOURCE FAMILY:
RELEASE OF INFORMATION
Name of County: _____________________________________________
Approved Relative/Nonrelative Extended Family Member (NREFM)
Licensed Foster Family Home
Parent Name #1: _____________________________________________
(Print Name)
Parent Name #2: _____________________________________________
(Print Name)
RELEASE OF INFORMATION:
I/We, _____________________________________ and, ______________________________________
(Print Parent Name #2)
(Print Parent Name #1)
hereby authorize the Department to transfer my/our foster family home file to the County for the purpose of
being approved as a Resource Family pursuant to Welfare and Institutions Code section 16519.5 and Health
and Safety Code section 1517.1.
I/We, _____________________________________ and, _____________________________________
(Print Parent Name #2)
(Print Parent Name #1)
hereby authorize the
Department
County
___________________________________________
(Adoption Agency Name)
to copy my/our approved homestudy and any updates to my/our adoption homestudy from my/our adoption file
and for said copies to be placed in my/our Resource Family file for the purpose of being deemed a Resource
Family pursuant to Welfare and Institutions Code section 16519.5. A closed homestudy cannot be accepted
for deeming purposes.
Upon approval as a Resource Family, I/we understand that my/our
Relative Approval
NREFM Approval
Foster Family Home license shall be forfeited by operation of law.
_______________________________________________________________________
____________
(Parent Name #1 Signature)
(Date)
_______________________________________________________________________
____________
(Parent Name #2 Signature)
(Date)
_______________________________________________________________________
____________
(Resource Family Worker Name)
(Resource Family Worker Signature)
(Date)
______________________________________________________________________________________
(Resource Family Worker Address)
_____________________________________
(Resource Family Worker Telephone Number)
RFA 00 (8/17) (Mandatory)
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