Online Inquiry

Click the 'Generate Form' link to pre-populate the form when you are ready.

<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 er_fld_fontstyle_bold">                                 Foster Parent Application
</div></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">Is this application for a Couple or Single Person?</label>
<label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_7" value="Couple ">Couple </label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_7" value="Single Person">Single Person</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_7" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_7_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Name_First_A">
<i class="fa fa-font"></i><label class="er_fld_label required">Single or Parent A First Name</label><input name="CST_1" type="text" class="er_fld_required er_fld_width100"><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Name_Last_A">
<i class="fa fa-font"></i><label class="er_fld_label required">Single or Parent A Last Name</label><input name="CST_93" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;">
<i class="fa fa-font"></i><label class="er_fld_label required">Single or Parent A Age:</label><input name="CST_42" type="text" class="er_fld_width25 er_fld_required"></li><li class="er_fld_type_date" draggable="false" style="width: 20%;" map_to="FH_DOB_A">
<i class="fa fa-calendar"></i><label class="er_fld_label required">Single Parent A DOB</label><input class="cst_datepicker er_fld_required er_fld_blank er_fld_width50" name="CST_4" 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 required">Single or Parent A Phone Number</label><input name="CST_92" type="text" class="er_fld_required er_fld_width100"></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">Single or Parent A Email</label><input name="CST_9" type="text" class="er_fld_required er_fld_width75"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+" map_to="FH_Name_First_B">
<i class="fa fa-font"></i><label class="er_fld_label required"> Parent B First Name</label><input name="CST_2" type="text" class="er_fld_required er_fld_blank er_fld_width75"><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+" map_to="FH_Name_Last_B">
<i class="fa fa-font"></i><label class="er_fld_label required">Parent B Last Name</label><input name="CST_94" type="text" class="er_fld_required er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+">
<i class="fa fa-font"></i><label class="er_fld_label required">Parent B Age:</label><input name="CST_43" type="text" class="er_fld_width25 er_fld_required"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+" map_to="FH_DOB_B">
<i class="fa fa-calendar"></i><label class="er_fld_label required">Parent B DOB</label><input class="cst_datepicker er_fld_required er_fld_blank er_fld_width50" name="CST_6" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+" map_to="FH_Phone_Mobile_B">
<i class="fa fa-font"></i><label class="er_fld_label required">Parent B Phone Number</label><input name="CST_8" type="text" class="er_fld_required er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+" map_to="FH_EMail_2">
<i class="fa fa-font"></i><label class="er_fld_label required">Parent B Email</label><input name="CST_3" type="text" class="er_fld_required er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;" map_to="FH_Address_Street_1">
<i class="fa fa-font"></i><label class="er_fld_label required">Home Address</label><input name="CST_10" type="text" class="er_fld_required" value=""></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;" map_to="FH_Address_City">
<i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_95" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;" map_to="FH_Address_State">
<i class="fa fa-font"></i><label class="er_fld_label required">State</label><input name="CST_96" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;" map_to="FH_Address_Zip">
<i class="fa fa-font"></i><label class="er_fld_label required">Zipcode</label><input name="CST_97" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;">
<i class="fa fa-font"></i><label class="er_fld_label required">How long have you lived at this address?</label><input name="CST_11" 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 required">Previous Address </label><input name="CST_12" 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">How long did you reside at previous address?</label><input name="CST_13" type="text" class="er_fld_required"><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_selected" draggable="false" style="width: 100%;">
<i class="fa fa-font"></i><label class="er_fld_label required">What are your T-shirt sizes?</label><input name="CST_99" type="text" class="er_fld_required er_fld_width50"></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 er_fld_fontstyle_bold">Members of Household:</div></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">Do you have your own children living in the home?</label>
<label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_31" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_31" 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_31" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_31_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_31" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Child 1 Name</label><input name="CST_19" type="text" class="er_fld_blank"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_31" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-calendar"></i><label class="er_fld_label">DOB</label><input class="cst_datepicker er_fld_blank" name="CST_20" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_31" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Child 2 Name</label><input name="CST_21" type="text" class="er_fld_blank"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_31" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-calendar"></i><label class="er_fld_label">DOB</label><input class="cst_datepicker er_fld_blank" name="CST_22" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_31" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Child 3 Name</label><input name="CST_23" type="text" class="er_fld_blank"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_31" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-calendar"></i><label class="er_fld_label">DOB</label><input class="cst_datepicker er_fld_blank" name="CST_24" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_31" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Child 4 Name</label><input name="CST_25" type="text" class="er_fld_blank"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_31" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-calendar"></i><label class="er_fld_label">DOB</label><input class="cst_datepicker er_fld_blank" name="CST_26" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_31" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Child 5 name</label><input name="CST_27" type="text" class="er_fld_blank"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_31" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-calendar"></i><label class="er_fld_label">DOB</label><input class="cst_datepicker er_fld_blank" name="CST_28" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_31" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Child 6 Name</label><input name="CST_29" type="text" class="er_fld_blank"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_31" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-calendar"></i><label class="er_fld_label">DOB</label><input class="cst_datepicker er_fld_blank" name="CST_30" type="text"><div data-lastpass-icon-root="true" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;"></div></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">Are there other adults living in the home besides the applicants?</label>
<label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_32" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_32" 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_32" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_32_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Adult 1 Name</label><input name="CST_33" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Adult 1 Age</label><input name="CST_34" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Relationship to Applicant</label><input name="CST_35" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Adult 2 Name</label><input name="CST_36" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Adult 2 Age</label><input name="CST_38" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Relationship to Applicant</label><input name="CST_37" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Adult 3 Name</label><input name="CST_40" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Adult 3 Age</label><input name="CST_41" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_32" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Relationship to Applicant</label><input name="CST_39" type="text" class="er_fld_blank"></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 have any pets?</label>
<label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_45" 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_45" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_45_Other" type="text"></label></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_45" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-paragraph"></i><label class="er_fld_label required">If yes, please list each pet, their type, age and temperament:</label><textarea name="CST_44" style="width:100%;" class="er_fld_required er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_45" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">I attest that all my pets are licensed and have had all their shots: </label>
<label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_46" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_46" 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 er_fld_blank" type="checkbox" name="CST_46" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_46_Other" type="text"></label></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_46" er_fld_condvals="er_fld_showif_values=No">
<i class="fa fa-font"></i><label class="er_fld_label required">If no, please explain</label><input name="CST_47" type="text" class="er_fld_blank er_fld_required"></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 er_fld_fontstyle_bold">Transportation</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">Do you have a current driver�s license? </label>
<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_48" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_48" 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_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" 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 have an automobile?</label>
<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_49" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_49" 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_49" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_49_Other" type="text"></label></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 your automobile adequately insured?</label>
<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_50" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_50" 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_50" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_50_Other" type="text"></label></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">Name of auto insurance company: </label><input name="CST_51" type="text" class="er_fld_required"></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 er_fld_fontstyle_bold">Education</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Single or Parent A (Indicate number of years completed)</label><select name="CST_52" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="12">12</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="GED">GED</option><option value="Master's">Master's</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Parent B (Indicate number of years completed)</label><select name="CST_53" class="er_fld_required er_fld_blank"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="12">12</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="GED">GED</option><option value="Master's">Master's</option></select></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 er_fld_fontstyle_bold">Employment</div></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 er_fld_fontstyle_info">Single or Parent A</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Employer_A">
<i class="fa fa-font"></i><label class="er_fld_label required">Current Employer:</label><input name="CST_55" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;">
<i class="fa fa-font"></i><label class="er_fld_label required">Address and Phone:</label><input name="CST_56" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Occupation_A">
<i class="fa fa-font"></i><label class="er_fld_label required">Position:</label><input name="CST_57" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;">
<i class="fa fa-font"></i><label class="er_fld_label required">Dates Employed:</label><input name="CST_54" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;">
<i class="fa fa-font"></i><label class="er_fld_label required">Previous Employer:</label><input name="CST_59" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;">
<i class="fa fa-font"></i><label class="er_fld_label required">Address and Phone:</label><input name="CST_60" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;">
<i class="fa fa-font"></i><label class="er_fld_label required">Position:</label><input name="CST_61" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;">
<i class="fa fa-font"></i><label class="er_fld_label required">Dates Employed:</label><input name="CST_58" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Parent B</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+" map_to="FH_Employer_B">
<i class="fa fa-font"></i><label class="er_fld_label required">Current Employer:</label><input name="CST_63" type="text" class="er_fld_required er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+">
<i class="fa fa-font"></i><label class="er_fld_label required">Address and Phone:</label><input name="CST_64" type="text" class="er_fld_required er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+" map_to="FH_Occupation_B">
<i class="fa fa-font"></i><label class="er_fld_label required">Position:</label><input name="CST_65" type="text" class="er_fld_required er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+">
<i class="fa fa-font"></i><label class="er_fld_label required">Dates Employed:</label><input name="CST_62" type="text" class="er_fld_required er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+">
<i class="fa fa-font"></i><label class="er_fld_label required">Previous Employer:</label><input name="CST_68" type="text" class="er_fld_required er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+">
<i class="fa fa-font"></i><label class="er_fld_label required">Address and Phone:</label><input name="CST_69" type="text" class="er_fld_required er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+">
<i class="fa fa-font"></i><label class="er_fld_label required">Position:</label><input name="CST_67" type="text" class="er_fld_required er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+">
<i class="fa fa-font"></i><label class="er_fld_label required">Dates Employed:</label><input name="CST_66" type="text" class="er_fld_required er_fld_blank"></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 er_fld_fontstyle_bold">Approximate Annual Household Income</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label required">Gross (before taxes)</label><input name="CST_70" type="text" class="er_fld_required"></li><li class="er_fld_type_number" draggable="false" style="width: 33.3333%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label required">Net (after taxes)</label><input name="CST_71" type="text" class="er_fld_required"></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 er_fld_fontstyle_bold">Foster/Adoptive Children</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false" map_to="FH_Interest"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Are you interested in?</label>
<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_72" value="Fostering">Fostering</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_72" value="Adopting">Adopting</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_72" value="Both">Both</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_content" draggable="false" style="width: 50%;">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Please indicate the type of child you are able to support: (Please check all that apply)</div></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">Gender:</label>
<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_73" value="Male">Male</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_73" value="Female">Female</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_73" value="Either">Either</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_73" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_73_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 required">Age Range:</label>
<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_74" value="0-5">0-5</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_74" value="6-12">6-12</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_74" value="13-18">13-18</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><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">Race:</label>
<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_75" value="Caucasian/White">Caucasian/White</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_75" value="African American/Black">African American/Black</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_75" value="Hispanic">Hispanic</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_75" value="Asian">Asian</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_75" value="Biracial">Biracial</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_75" value="Any/All">Any/All</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_75" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_75_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">Emotional/Behavioral Issues:</label>
<label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_77" value="Mild">Mild</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_77" value="Moderate">Moderate</label><label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_77" value="Severe">Severe</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_77" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_77_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 required">Medical Issues:</label>
<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_78" value="Mild">Mild</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_78" value="Moderate">Moderate</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_78" value="Severe">Severe</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_78" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_78_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 required">Intellectual Disabilities</label>
<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_76" value="Mild">Mild</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_76" value="Moderate">Moderate</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_76" value="Severe">Severe</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_76" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_76_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 er_fld_fontstyle_bold">PRIOR FOSTER/ADOPTIVE PARENTING EXPERIENCE</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">Have you ever applied to or worked with another agency as a foster or adoptive parent? </label>
<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_79" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_79" 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_79" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_79_Other" type="text"></label></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_79" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">If yes, when and what agency?</label><input name="CST_80" type="text" class="er_fld_blank"></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 er_fld_fontstyle_bold">MOTIVATION TO FOSTER AND/OR ADOPT</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;">
<i class="fa fa-paragraph"></i><label class="er_fld_label required">What are your top 3 reasons for wanting to be a foster/adoptive parent? </label><textarea name="CST_82" style="width:100%;" class="er_fld_required">1.

</textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 50%;">
<i class="fa fa-paragraph"></i><label class="er_fld_label required">What characteristics or life experience do you have that equip you to support a child who has experienced trauma in their life? </label><textarea name="CST_83" style="width:100%;" class="er_fld_required"></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">Per state standards foster parents must complete two different types of background checks. Is there anything that would come up on those for any of the adults living in your home?</label>
<label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_85" value="Yes">Yes</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_85" 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_85" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_85_Other" type="text"></label></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_85" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-paragraph"></i><label class="er_fld_label required">If yes, explain:</label><textarea name="CST_86" style="width:100%;" class="er_fld_required er_fld_blank"></textarea></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 required">What is your childcare plan?</label><textarea name="CST_87" style="width:100%;" class="er_fld_required"></textarea></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 er_fld_fontstyle_bold">Applicant References</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large" draggable="false" style="width: 50%;">
<i class="fa fa-paragraph"></i><label class="er_fld_label required">Single or Parent A References (Must have 3)</label><textarea name="CST_88" style="width:100%;" class="er_fld_required er_fld_copypre">Name:
Phone:

Name:
Phone:

Name:
Phone:</textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_showif er_fld_type_paragraph_large" draggable="false" style="width: 50%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+">
<i class="fa fa-paragraph"></i><label class="er_fld_label required">Parent B References (Must have 3)</label><textarea name="CST_89" style="width:100%;" class="er_fld_required er_fld_blank">Name:
Phone:

Name:
Phone:

Name:
Phone:</textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="FH_Inquiry_How_Referred">
<i class="fa fa-font"></i><label class="er_fld_label required">How were you referred to us?</label><input name="CST_98" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 50%;">
<i class="fa fa-pencil"></i><label class="er_fld_label required">Single or Parent A</label><div class="cst_signaturepad"></div><input name="CST_90" type="text" class="er_fld_required" field_code="<*ES1>, <*EN1>, and <*ED1>"><button class="type_button" disabled="">Clear Signature</button></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_7" er_fld_condvals="er_fld_showif_values=Couple+">
<i class="fa fa-pencil"></i><label class="er_fld_label required">Parent B</label><div class="cst_signaturepad"></div><input name="CST_91" type="text" class="er_fld_required er_fld_blank" field_code="<*ES2>, <*EN2>, and <*ED2>"><button class="type_button" disabled="">Clear Signature</button></li></ul>