Ariz. Admin. Code § R21-6-403 - Application for an Initial License

A. An individual or married couple shall complete the application for an initial license accurately and in full via the Department's electronic database. The applicant may direct the licensing agency to enter the application.

B. The application for an initial license shall include:

1. The full legal name of each household member;

2. All other names and aliases, including birth names and names used in previous marriages, of each household member;

3. The current marital status of the applicant;

4. The date of birth of each household member, except other foster children, including evidence that the applicant is at least 21 years of age;

5. The Social Security Number of each adult household member, for the purpose of conducting a background check;

6. The relationship between the applicant and all other household members, including a parent, sibling, housemate, or tenant;

7. The telephone number and e-mail address of the applicant;

8. The mailing address of the applicant and the physical address of the applicant's home;

9. A statement that the applicant resides in Arizona;

10. The document specified under A.R.S. § 41-1080(A) and, as applicable (E), to demonstrate that the applicant is lawfully present in the United States;

11. The name of the school district in which the applicant's home is located;

12. Each address held by each adult household member during the previous 10 years;

13. The name, date of birth, current address, and telephone number of each child of the applicant who lives outside the applicant's home, if known, and a statement as to whether the child is reasonably expected to have contact with a child in foster placement;

14. The applicant's employment history, including the names of employers, dates of employment, and positions held during the previous 10 years;

15. A summary of the applicant's education;

16. A description of the applicant's experience in caring for children or adults;

17. The applicant's household budget, showing income, resources, assets, debts, and obligations;

18. Plans for the sleeping arrangements for each household member and for each potential foster child;

19. Plans for transportation of each potential foster child including:

a. Evidence of a valid driver license for each household member who will provide transportation;

b. Evidence that each vehicle to be used for transportation is registered and insured to operate in Arizona; and

c. Evidence that the applicant has or shall obtain prior to placement, the correct number and type of child car seats for the conditions of the license.

20. A description of any pool on the foster home premises;

21. A description of the applicant's prior efforts to be certified or licensed for adoption, foster care, assisted living, child-care, and any other service for children or vulnerable adults, including:

a. Applications that were withdrawn or denied; and

b. Applications that resulted in a license or certification that was suspended or revoked.

22. A list of the names, mailing and e-mail addresses, and telephone numbers of five references, to attest that the applicant is of good character and has the qualifications to care for a foster child:

a. At least one of the references, but not more than two, shall be related to the applicant;

b. At least three of the references shall be unrelated to the applicant;

c. If the applicant is married, then at least two of the references shall be familiar with the applicant as a couple; and

d. If another adult household member is applying for a license or is currently licensed, then at least two of the references shall be familiar with both the applicant or foster parent and other household member.

23. A disclosure of civil and court proceedings in which the applicant has been a party, including:

a. Criminal proceedings;

b. Lawsuits;

c. Dependency actions, including:

i. Removal of a dependent,

ii. Voluntary relinquishment,

iii. Suspension of custody, or

iv. Termination of parental rights;

d. Charges of child abuse or neglect;

e. Child support enforcement proceedings within the last five years;

f. Bankruptcy within the last five years;

g. Divorce, separation, or any other civil proceedings; and

h. Adoption;

24. A criminal record self-disclosure completed by each adult household member;

25. Evidence that each adult household member, has obtained a Level One fingerprint clearance card;

26. A disclosure by the applicant of any allegation against the applicant of abuse or neglect of any child or vulnerable adult;

27. Any history of abuse or neglect involving the applicant;

28. Authorization for a Central Registry record check:

a. For each adult household member, and

b. With each state in which any adult household member resided in during the previous five years.

29. A health self-disclosure completed by each adult household member;

30. A physician's statement as defined in R21-6-101(54), related to the physical and behavioral health completed for the applicant and for each adult household member who will be providing care and supervision;

31. An up-to-date immunization record, if available, for each child household member. The lack of available immunization records shall not prohibit licensure, but may be grounds for restricting the license to prevent the placement of infants, young children, and medically complex individuals; and

32. A Statement of Understanding signed by the applicant and attesting to the truth of the information provided during the application process.

C. The applicant in cooperation with a licensing agency shall submit the information required under R21-6-205 and this Section and the home study and assessment as directed under R21-6-206 and R21-6-405.

Notes

Ariz. Admin. Code § R21-6-403

New section made by exempt rulemaking at 21 A.A.R. 3480, effective 1/24/2016.