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_dropdown" draggable="false" style="width: 50%;" map_to="FH_Interest"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Interested In</label><select name="CST_20" class="er_fld_required"><option value="-Not Specified-" selected="">-Not Specified-</option><option value="Foster Parent/Respite">Foster Parent/Respite</option><option value="Host Home Provider">Host Home Provider</option><option value="Dual Certified (FP/HHP)">Dual Certified (FP/HHP)</option><option value="Kinship">Kinship</option><option value=""></option></select></li><li class="er_fld_type_date" draggable="false" style="width: 50%;">
<i class="fa fa-calendar"></i><label class="er_fld_label required">Inquiry Date</label><input class="cst_datepicker er_fld_required" name="CST_112" type="text"></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_20" er_fld_condvals="er_fld_showif_values=Host+Home+Provider">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">At this time, we are only accepting host home provider inquiries who are willing to be dual-certified as both a foster parent and host home provider. Beginning with the foster parent approval process first. </div></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_20" er_fld_condvals="er_fld_showif_values=Enhanced+Home">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">If you are interested in becoming an Enhanced Parent, the following guidelines are required:

You are currently renting and your lease is coming to an end. Or you currently own a home and have plans to sell it in the near future.
You are getting ready or are willing to move.
You can commit a minimum of one year to the role. 
You work from home or have a flexible work schedule. If neither of these conditions applies to you, you can add a secondary parent who works from home or has a flexible work schedule.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_20" er_fld_condvals="er_fld_showif_values=Enhanced+Home"><i class="fa fa-caret-down"></i><label class="er_fld_label">I agree to the Enhanced Home guidelines</label><select name="CST_91"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></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_91" er_fld_condvals="er_fld_showif_values=No">
<i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">If you answered "No" to the Enhanced Home guidelines CCS will not be able to process your inquiry.</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">Are you currently with another agency or have an application submitted with another agency?</label><select name="CST_61" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Have you ever inquired with CCS before?</label><select name="CST_111" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="FH_Name_First_A" style="width: 33.3333%;">
<i class="fa fa-font"></i><label class="er_fld_label required">Primary Applicant First Name</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Name_Last_A">
<i class="fa fa-font"></i><label class="er_fld_label required">Primary Applicant Last Name</label><input name="CST_3" type="text" class="er_fld_required"></li><li class="er_fld_type_date" draggable="false" style="width: 33.3333%;" map_to="FH_DOB_A">
<i class="fa fa-calendar"></i><label class="er_fld_label required">Primary Applicant Date of Birth</label><input class="cst_datepicker er_fld_required" name="CST_28" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Gender_A">
<i class="fa fa-font"></i><label class="er_fld_label">Gender</label><input name="CST_25" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Race_A">
<i class="fa fa-font"></i><label class="er_fld_label">Race</label><input name="CST_26" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Religion_A">
<i class="fa fa-font"></i><label class="er_fld_label">Religion</label><input name="CST_27" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="FH_Language"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Primary Language Spoken</label><select name="CST_98" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="English">English</option><option value="Spanish">Spanish</option><option value="French">French</option><option value="Arabic">Arabic</option><option value="Other, please specify">Other, please specify</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_98" er_fld_condvals="er_fld_showif_values=Other%2C+please+specify">
<i class="fa fa-font"></i><label class="er_fld_label required">Primary Language Spoken</label><input name="CST_99" 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%;" map_to="FH_Address_Street_1">
<i class="fa fa-font"></i><label class="er_fld_label required">Address Line 1</label><input name="CST_4" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="FH_Address_Street_2">
<i class="fa fa-font"></i><label class="er_fld_label required">Address Line 2</label><input name="CST_2" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Address_City">
<i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_11" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Address_State">
<i class="fa fa-font"></i><label class="er_fld_label required">State</label><input name="CST_12" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Address_Zip">
<i class="fa fa-font"></i><label class="er_fld_label required">Zip Code</label><input name="CST_14" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_Address_County">
<i class="fa fa-font"></i><label class="er_fld_label required">County</label><input name="CST_15" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" draggable="false" style="width: 25%;" map_to="FH_Phone_Home">
<i class="fa fa-hashtag"></i><label class="er_fld_label required">Phone Number</label><input name="CST_10" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_EMail">
<i class="fa fa-font"></i><label class="er_fld_label required">Email Address</label><input name="CST_5" type="text" class="er_fld_required"></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">Have you lived in Georgia the last 5 years?</label><select name="CST_65" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="FH_NumBedrooms"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Number of Bedrooms in the home</label><select name="CST_42" 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></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Number of Bathrooms in the home</label><select name="CST_45" 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></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Number of Bedrooms available for placement</label><select name="CST_87" 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=""></option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Wheelchair accessible or able to modify for accessibility</label><select name="CST_86"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Preferred Method of Contact?</label><select name="CST_60"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Phone Calls">Phone Calls</option><option value="Text">Text</option><option value="Emails">Emails</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="FH_MaritalStatus"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Relationship status</label><select name="CST_83" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Single">Single</option><option value="Married">Married</option><option value="Married but separated">Married but separated</option><option value="Divorced">Divorced</option><option value="Widowed">Widowed</option><option value="Partnership">Partnership</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_First_B" er_fld_condvals="">
<i class="fa fa-font"></i><label class="er_fld_label">Secondary Parent First Name</label><input name="CST_7" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Name_Last_B">
<i class="fa fa-font"></i><label class="er_fld_label">Secondary Parent Last Name</label><input name="CST_8" type="text"></li><li class="er_fld_type_date" draggable="false" style="width: 25%;" map_to="FH_DOB_B">
<i class="fa fa-calendar"></i><label class="er_fld_label">Secondary Applicant Date of Birth</label><input class="cst_datepicker" name="CST_41" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Gender_B">
<i class="fa fa-font"></i><label class="er_fld_label">Gender</label><input name="CST_30" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Race_B">
<i class="fa fa-font"></i><label class="er_fld_label">Race</label><input name="CST_29" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;" map_to="FH_Religion_B">
<i class="fa fa-font"></i><label class="er_fld_label">Religion</label><input name="CST_32" type="text"></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">Primary Language Spoken</label><select name="CST_100" class=""><option value="- Not Specified -" selected="">- Not Specified -</option><option value="English">English</option><option value="Spanish">Spanish</option><option value="French">French</option><option value="Arabic">Arabic</option><option value="Other, please specify">Other, please specify</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_100" er_fld_condvals="er_fld_showif_values=Other%2C+please+specify">
<i class="fa fa-font"></i><label class="er_fld_label">Primary Language Spoken</label><input name="CST_101" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_number" draggable="false" style="width: 20%;" map_to="FH_Phone_Other">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Phone Number</label><input name="CST_67" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="FH_EMail_2">
<i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_17" type="text"></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">Other Household members residing in the home?</label><select name="CST_35" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></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_35" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Name of Household Member</label><input name="CST_22" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 20%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_24" type="text"></li><li class="er_fld_type_date" draggable="false" style="width: 20%;">
<i class="fa fa-calendar"></i><label class="er_fld_label">Date of Birth</label><input class="cst_datepicker" name="CST_68" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;">
<i class="fa fa-font"></i><label class="er_fld_label">Relationship</label><input name="CST_46" type="text"></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_35" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-font"></i><label class="er_fld_label">Name of Household Member</label><input name="CST_37" type="text"></li><li class="er_fld_type_number" draggable="false" style="width: 20%;">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Age</label><input name="CST_39" type="text"></li><li class="er_fld_type_date" draggable="false" style="width: 20%;">
<i class="fa fa-calendar"></i><label class="er_fld_label">Date of Birth </label><input class="cst_datepicker" name="CST_69" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;">
<i class="fa fa-font"></i><label class="er_fld_label">Relationship</label><input name="CST_47" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_35" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-paragraph"></i><label class="er_fld_label">Additional household member information</label><textarea name="CST_51" style="width:100%;">Name:
Age:
DOB:
Relationship:

Name:
Age:
DOB:
Relationship</textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Are there frequent visitors in the home?</label><select name="CST_36" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_36" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-paragraph"></i><label class="er_fld_label">If there are frequent visitors in the home, list their information </label><textarea name="CST_48" style="width:100%;" class="">Name:
Age:
Relationship:
How often in the home:

Name:
Age:
Relationship:
How often in the home:</textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Do you have pets in the home?</label><select name="CST_49" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_paragraph er_fld_type_paragraph_large er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_49" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-paragraph"></i><label class="er_fld_label">If you have pets, please answer? </label><textarea name="CST_50" style="width:100%;">Type:
Breed:
Age:
Name:

Type:
Breed:
Age:
Name:</textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="none"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Primary Applicant Drivers License</label><select name="CST_53" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="none"><i class="fa fa-caret-down"></i><label class="er_fld_label">Secondary Applicant Drivers License</label><select name="CST_54"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_53" er_fld_condvals="er_fld_showif_values=Yes" map_to="FH_DL_A">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Primary Applicant Drivers License #</label><input name="CST_57" type="text"></li><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_54" er_fld_condvals="er_fld_showif_values=Yes" map_to="FH_DL_B">
<i class="fa fa-hashtag"></i><label class="er_fld_label">Secondary Applicant Drivers License #</label><input name="CST_58" type="text" value=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Do you have reliable transportation?</label><select name="CST_52" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 33.3333%;">
<i class="fa fa-paragraph"></i><label class="er_fld_label required">Do you have any driving restrictions? if so, please list.</label><textarea name="CST_88" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 20%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Primary Applicant - Are you currently employed?</label><select name="CST_71" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_71" er_fld_condvals="er_fld_showif_values=Yes" map_to="FH_Employer_A">
<i class="fa fa-font"></i><label class="er_fld_label required">Employer</label><input name="CST_72" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_71" er_fld_condvals="er_fld_showif_values=Yes" map_to="FH_Occupation_A">
<i class="fa fa-font"></i><label class="er_fld_label required">Occupation</label><input name="CST_73" type="text" class="er_fld_required"></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_71" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-paragraph"></i><label class="er_fld_label required">Work Schedule</label><textarea name="CST_75" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_71" er_fld_condvals="er_fld_showif_values=No"><i class="fa fa-caret-down"></i><label class="er_fld_label">If not employed, do you receive income? </label><select name="CST_94"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_94" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-paragraph"></i><label class="er_fld_label">If yes you are not employed; however, do receive income, please explain</label><textarea name="CST_95" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_medium" draggable="false" style="width: 25%;">
<i class="fa fa-paragraph"></i><label class="er_fld_label required">Availability outside of work/school</label><textarea name="CST_84" style="width:100%;" class="er_fld_required"></textarea></li><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Are you in school</label><select name="CST_89"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 25%;">
<i class="fa fa-paragraph"></i><label class="er_fld_label">Paragraph</label><textarea name="CST_90" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 20%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Secondary Applicant - Are you currently employed?</label><select name="CST_76"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_76" er_fld_condvals="er_fld_showif_values=Yes" map_to="FH_Employer_B">
<i class="fa fa-font"></i><label class="er_fld_label">Employer</label><input name="CST_77" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_76" er_fld_condvals="er_fld_showif_values=Yes" map_to="FH_Occupation_B">
<i class="fa fa-font"></i><label class="er_fld_label">Occupation</label><input name="CST_78" type="text"></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_76" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-paragraph"></i><label class="er_fld_label">Work Schedule</label><textarea name="CST_79" style="width:100%;"></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">Schedule availability outside of work/school.</label><textarea name="CST_85" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">(Primary Caregiver) Do you have any child caregiving experience? </label><select name="CST_106" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></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_106" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-paragraph"></i><label class="er_fld_label">If you have child caregiving experience please explain</label><textarea name="CST_107" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">(Primary Caregiver) Have you ever been convicted of a felony?</label><select name="CST_62" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">(Primary Caregiver) Have you ever had a CPS allegation?</label><select name="CST_64" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></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">if you have been convicted of a felony or had a CPS allegation please explain.</label><textarea name="CST_102" style="width:100%;"></textarea></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">(Secondary Caregiver, if applicable) Do you have any child caregiving experience? </label><select name="CST_108" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option><option value="NA">NA</option></select></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_108" er_fld_condvals="er_fld_showif_values=Yes">
<i class="fa fa-paragraph"></i><label class="er_fld_label">If you have child caregiving experience please explain</label><textarea name="CST_110" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">(Secondary Caregiver, if applicable) Have you ever been convicted of a felony?</label><select name="CST_103" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option><option value="NA">NA</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">(Secondary Caregiver, if applicable) Have you ever had a CPS allegation?</label><select name="CST_104" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option><option value="NA">NA</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 100%;">
<i class="fa fa-paragraph"></i><label class="er_fld_label">if you have been convicted of a felony or had a CPS allegation please explain.</label><textarea name="CST_105" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">How did you hear about us? </label><select name="CST_92" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Search Engine (Google, Bing, etc.)">Search Engine (Google, Bing, etc.)</option><option value="Brochure">Brochure</option><option value="Resource Fair">Resource Fair</option><option value="Facebook">Facebook</option><option value="Instagram">Instagram</option><option value="Word of Mouth">Word of Mouth</option><option value="Raise a Child">Raise a Child</option><option value="Agency (Please specify)">Agency (Please specify)</option><option value="Current foster parent/host home provider (Please specify)">Current foster parent/host home provider (Please specify)</option><option value="Other (Please specify)">Other (Please specify)</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_92" er_fld_condvals="er_fld_showif_values=Referral+(Please+specify)&amp;er_fld_showif_values=Other+(Please+specify)">
<i class="fa fa-font"></i><label class="er_fld_label required">Referral/Other, please specify</label><input name="CST_93" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown er_fld_selected" draggable="false" style="width: 25%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Choose next Orientation Date/Time</label><select name="CST_80" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value=""></option><option value="Wednesday, September 11th, virtual @11:00am">Wednesday, September 11th, virtual @11:00am</option><option value=""></option><option value="Wednesday, September 18th, virtual @ 5:00pm">Wednesday, September 18th, virtual @ 5:00pm</option><option value=""></option><option value="Wednesday, October 9th, virtual @11:00am">Wednesday, October 9th, virtual @11:00am</option><option value=""></option><option value="Wednesday, October 16th, virtual @ 5:00pm">Wednesday, October 16th, virtual @ 5:00pm</option><option value=""></option><option value="Wednesday, October 23rd, virtual @ 5:00pm">Wednesday, October 23rd, virtual @ 5:00pm</option><option value=""></option><option value="Wednesday, November 6th, virtual @11:00am">Wednesday, November 6th, virtual @11:00am</option><option value=""></option><option value="Wednesday, November 13th, virtual @ 5:00pm">Wednesday, November 13th, virtual @ 5:00pm</option><option value=""></option><option value="Wednesday, November 20th, virtual @ 5:00pm">Wednesday, November 20th, virtual @ 5:00pm</option><option value=""></option><option value="Wednesday, December 4th, virtual @11:00am">Wednesday, December 4th, virtual @11:00am</option><option value=""></option><option value="Wednesday, December 11th, virtual @ 5:00pm">Wednesday, December 11th, virtual @ 5:00pm</option><option value=""></option><option value="Wednesday, December 18th, virtual @ 5:00pm">Wednesday, December 18th, virtual @ 5:00pm</option><option value=""></option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;" map_to="FH_Inquiry_Why_Parents">
<i class="fa fa-paragraph"></i><label class="er_fld_label required">Why do you want to be a foster parent or host home provider? </label><textarea name="CST_82" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" style="width: 50%;" draggable="false">
<i class="fa fa-pencil"></i><label class="er_fld_label">Signature</label><div class="cst_signaturepad"></div><input name="CST_9" type="text"><button class="type_button" disabled="">Clear Signature</button></li></ul>