STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
VII. CHILD OR NONMINOR DEPENDENT PLACED IN THE CALENDAR YEAR OF 2017
I
I
Is the child or NMD currently in your home? Check one:
Yes
No
If yes, complete LIC 01C.
G
VIII. CHILD DESIRED
Please indicate your preference for characteristics of a child/NMD to be placed with you.
AGE(S)
I
I
I
I
I
I
I
0 TO 3 yrs
4 TO 8 yrs
9 TO 12 yrs
13 TO 15 yrs
16 TO 18 yrs
18 TO 21 yrs
No preference
SIBLING (GROUP OF)
I
I
I
I
I
0
2
3
4
5 or more
IX. FOSTER CARE/ADOPTION/ LICENSURE HISTORY
Have you been previously licensed, certified, or approved to provide foster care?
G
If yes, name of agency(s): ______________________________________________________________________________
Type of license/certification/approval: _____________________________________________________________________
Have you previously applied for adoption?
G
If yes, name of agency(s): _______________________________________________________________________
Have you previously been licensed to operate a non-foster care community care facility, child care center, family child care
G
home, or residential care facility for the elderly or chronically ill?
If yes, type of license: __________________________________________________________________________
Have you previously been employed by or volunteered at a community care facility, child care center, family child
G
care home, or residential care facility for the elderly or chronically ill?
If yes, name the facility(s): _______________________________________________________________________
Have you had a previous license, certification, relative or nonrelative extended family member approval, or resource family
G
approval application denial?
I
I
Check one:
Yes
No
If yes, name of agency(s): _______________________________________________________________________
Have you had a license, certification, or approval suspended, revoked, or rescinded?
G
I
I
Check one:
Yes
No
If yes, name of agency(s): _______________________________________________________________________
Have you been subject to an exclusion order?
G
I
I
Check one:
Yes
No
LIC 00A (2/17) (Mandatory)
CONVERSION - RESOURCE FAMILY APPLICATION
PAGE 3 OF 4