Fairfax County Foster Care & Adoption Association
P.O. Box 2882
Springfield, VA 22152

Membership Form

Please complete and mail to the above address

Name(s)_________________________________________________________

Address ________________________________________________________

(city)_________________________________________, (state)______ (zip)____- ________

Telephone Home: (____) ___________, Office (____) ____________

Numbers Fax: (____) ____________

Donation Included ($12 is our goal) ______Yes ______No

Interests: Please indicate which issues you would like to assist in addressing

______Education – Assist in training new foster families and continuing education for current foster families.

______Finance – fund raising, including corporate and foundation grants

______Program – organize meetings, seminars, conference participation, etc.

______Publicity – inform membership and the public about foster care, includes newsletter, establish advocacy program

______Phone Tree – team of members who telephone membership in advance of activities

______Web Site – help develop an internet web site.

______Welfare – recruit membership, develop clothing banks, inform membership of available resources

______Other interest areas (please specify)

Foster Family Background Data

For internal use only all responses will be kept confidential

1. Year you first became a foster parent(s) ____. Year you became a Fairfax County foster parent(s) ____.
2. Single parent family ______, Two parent family ______, Other (please explain)_____
3. Stay at home foster parent in the family ______.
4. Number of children of your own _________.
5. Number of foster children presently in your home_______.
6. What age ranges do you accept _____________.
7. Do you intend to adopt children? ____yes, ____no, _____undecided
8. What type of care do you provide? ____emergency, ____short-term, ____long-term, ____therapeutic
9. Do you accept "special needs" children? ____yes, ____no

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