Thank you for completing your Thornwell Foster Care Intake Application. If you have any questions or concerns, please contact Kaley Lindquist (klindquist@thornwell.org). How did you first hear about Thornwell's Foster Care program?Today's Date MM slash DD slash YYYY Applicant OneYour Name(Required) First Last Any aliases/maiden name if applicable(Required)Date of Birth(Required) MM slash DD slash YYYY Gender(Required)Phone/Alt Phone(Required)Email(Required) Physical Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address (if different) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Employer/Job Title(Required)Applicant TwoName First Last Any aliases/maiden name if applicableDate of Birth MM slash DD slash YYYY GenderYour Phone/Alt PhoneEmail Employer/Job TitlePlacement PreferencesWe'd like to know what children and youth you are open to fostering in your home. Placement preferences will be an ongoing discussion. You are not bound to the preferences you list on this intake application. Please share the widest range you feel comfortable with.Number of Children(Required)Age Range(Required)Gender(Required)I am willing to foster Youth who identify as LGBTQ+ Children who speak primarily or only Spanish/ other language Pregnant and parenting youth Household MembersPlease list all additional children/adults who live full-time or part-time in your home. If more entries are needed, notify us after submission.Full NameBirthdate MM slash DD slash YYYY GenderRelationshipGrade/OccupationFull-time/Part-time OccupantFull NameBirthdate MM slash DD slash YYYY GenderRelationshipGrade/OccupationFull-time/Part-time OccupantFull NameBirthdate MM slash DD slash YYYY GenderRelationshipGrade/OccupationFull-time/Part-time OccupantFull NameBirthdate MM slash DD slash YYYY GenderRelationshipGrade/OccupationFull-time/Part-time OccupantLiving Outside of South Carolina in Last Five YearsAPPLICANT ONE | In the past five years have you lived outside of South Carolina?(Required) Yes No If yes, complete the following questions:Name of Person Living Outside of South Carolina First Last State/CountryDatesAPPLICANT ONE | Do you have a criminal record?(Required) Yes No If yes, complete the following questions:Name First Last Date of Arrest MM slash DD slash YYYY Arrest ChargeTell Us More:APPLICANT TWO | In the past five years have you lived outside of South Carolina? Yes No If yes, complete the following questions:Name of Person Living Outside of South Carolina First Last State/CountryDatesAPPLICANT TWO | Do you have a criminal record? Yes No If yes, complete the following questions:Name First Last Date of Arrest MM slash DD slash YYYY Arrest ChargeTell Us More:SignaturesApplicant One Signature(Required)Please type your name. Your physical signature will be required on the rest of your application materials.Today's Date MM slash DD slash YYYY Applicant Two SignatureToday's Date MM slash DD slash YYYY
