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Juvenile Justice Center Family Services of Philadelphia
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If you are interested in becoming a foster parent please fill out and submit the form below. You may also fill out a printed version of the form and mail it to:

JJC Family Services
100 West Coulter St.
Philadelphia, Pa 19144-3402
Attn: Jeanine Glasgow

Contact Information
Male's First Name: Last Name:
Female's First Name: Last Name:
Address:  
 
City: State:
Zip:  
 
Home Phone:  
 

Members of Household
Number of Adults Number of Children

Housing Information
Any Major Repairs Needed? Yes No
Please select one the following three.
Yes, I rent
Yes, I pay mortage
Yes, I own my house
Type of Home: Number of Bedrooms:

Employment Information
Male Applicant Female Applicant
Occupation Occupation
Business Phone: Business Phone:
Work Schedule: Work Schedule:
Income: Income:
If not working, what is the applicants' source(s) of income?
 
What is the monthly income?
 

Interested In:  
Age: Sex:
From: To: Male Female
Number of:  
 
Referred By: Why foster care?
Experience working with clildren who have emotional/behavior problems:
Willingness to work with children with these probelms:
Willingness to accept temporary placement:

Agency Affliation
Are you currently with a foster agency?
Yes No
Have you ever applied to another foster care or adoption agency?
Yes No