ࡱ> '` S bjbjLULU *.?.?P2& & & & & & & : OOO8p: kPSSSSTaUlU8j9k9k9k9k9k9k$mho,]kQ& VTTVV]k& & SSkZZZVd& S& SjZVjZZ:<`,& & `S ?OVdh` bk0kr`R*qNW*q`*q& `<VVZ'V 3VSVVV]k]kYVVVkVVVV: : : #-$": : : -: : : & & & & & &  FOSTER HOME LICENSING REQUIREMENTS FOR RELATIVE CAREGIVERSMichigan Department of Human ServicesRelative Caregiver(s) NameMaiden Name (if applicable)Relative Caregiver(s) Date of Birth1) FORMTEXT       FORMTEXT       FORMTEXT      2) FORMTEXT       FORMTEXT       FORMTEXT      Relative Caregiver(s) AddressRelative Caregiver(s) Phone FORMTEXT       FORMTEXT      Name of Child(ren) Placed in Relative Caregiver(s) Home:Relative s Relationship to the Child:Case Number(s)SWSS Log #:1) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      2) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      3) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      4) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      5) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Foster Care Worker NameFoster Care Worker PhoneFoster Care Worker Load NumberDHS County or PAFC Provider Name:Date Referred to Agency for Licensure: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      The requirements for foster home licensing include: FORMCHECKBOX Home Study A certification worker will conduct a licensing study to assess your family, parenting, ability to plan long term for the relative child and to ensure that your home meets licensing standards and is a safe environment for foster children. The process needs to be completed within 90 days of placement. FORMCHECKBOX Home Visits A certification worker will visit your home to complete an assessment.  FORMCHECKBOX Training All adult caregivers in the household must complete a minimum of 12 hours of training before licensure. Once licensed, there will be additional annual training requirements. FORMCHECKBOX Fingerprints All caregivers living in your home will be fingerprinted to conduct a criminal history check. Other adults living in the household will have to submit to a check of Michigan State Police criminal history records. There will be a review of child abuse and neglect records for all adults living in your home. The Sex Offender Registry will also be checked for adults and youth who are members of the household or give the home as their address. FORMCHECKBOX References You must provide references from three unrelated persons who can attest to your character and suitability for becoming a licensed foster home. FORMCHECKBOX Health of Family All members of your household must provide medical statements as part of the licensing process. FORMCHECKBOX Discipline You must follow the behavior management plan developed for each child by the agency which includes refraining from the use of physical discipline. FORMCHECKBOX Valid Drivers license All household members transporting a child must have a valid drivers license and active auto insurance. The financial benefits of being licensed: FORMCHECKBOX Foster care payments between $398.72 and $492.52 per month at a minimum depending on the age of the child. Foster care payment begins the effective date of your foster home license.  FORMCHECKBOX Child may be eligible for an initial clothing allowance up to $500.00 depending on the age and need of the child. Need is based on the childs clothing inventory. FORMCHECKBOX Child is eligible for a semi-annual clothing allowance between $107.00 and $122.00 depending on the age of the child. FORMCHECKBOX Holiday allowance of $25.00 per child. FORMCHECKBOX Foster parents who provide care above and beyond what would normally be expected to meet the special needs of a child may be eligible for increased daily rate payments. FORMCHECKBOX Reimbursement for tutoring, graduation expenses, and some transportation expenses are available if eligibility requirements are met.Relative decision to pursue licensure as a foster family home: FORMCHECKBOX I am interested in pursuing licensure and I understand that certification worker will contact me within 7 days. FORMCHECKBOX I certify, to the best of my knowledge, that no adult member of the household has a criminal background that would prohibit licensure as a foster family home. FORMCHECKBOX I certify, to the best of my knowledge, that I (and all other adult household caregivers) am willing to be fingerprinted for the purpose of criminal background checks as required for becoming licensed as a foster family home. FORMCHECKBOX I certify, to the best of my knowledge, that no adult member of the household is substantiated as a perpetrator for child abuse or neglect. FORMCHECKBOX I certify, to the best of my knowledge, that no juvenile or adult household member is an adjudicated or registered sex offender. FORMCHECKBOX I certify that I am willing and able to complete the training that is required to become a licensed foster family home. FORMCHECKBOX I certify that I will comply with the licensing process within the 90 day timeframe and let my certification worker know immediately if I need assistance in meeting any requirements if barriers arise. FORMCHECKBOX I certify that I have a legal source of income to meet my familys needs. FORMCHECKBOX I received a copy of the DVD or VHS Foster Parenting What Every Parent Needs to Know. FORMCHECKBOX I received a copy of the Study Questions related to the DVD or VHS Foster Parenting What Every Parent Needs to Know. FORMCHECKBOX I received a copy of the booklet Relative Caregiving: What You Need to Know. FORMCHECKBOX I am willing and able to provide long-term placement, if necessary.,Ft 6 8 ~    " , . 0 2 F H J T V X Z n ԷЬԷ왤ЎԷЃԷjhMUj#hMUjhiUjhiUj:hMUjh(UmHnHujhMUh! (jh! 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(Complete Waiver of Foster Home Licensure, DHS-875 with relative caregiver.) FORMCHECKBOX  I understand that a Foster Care Worker will visit my home monthly.Relative Signature/Relationship to ChildDateRelative Signature/Relationship to ChildDateWorker SignatureDateDepartment of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.     DHS-972 (Rev. 2-11) Previous edition obsolete. 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