ࡱ>  @ ?ybjbj ) '<<<8d<S(=>????s@\@0R[S[S[S[S[S[S$URWS9tB??tBtBS??SDDDtB(??RDtBRDD:J,&K?, @x}<B(J LS0SJRXBX&KX4K@>=A,DiA$A@@@SS"DD"FOSTER HOME LICENSING REQUIREMENTS FOR RELATIVE CAREGIVERSMichigan Department of Human ServicesRelative Caregiver(s) NameRelative Caregiver(s) Date of Birth FORMTEXT       FORMTEXT      Relative Caregiver(s) AddressRelative Caregiver(s) Phone FORMTEXT       FORMTEXT      Name of Child(ren) Placed in Relative Caregiver(s) Home:Case Number(s) FORMTEXT       FORMTEXT      SWSS Log #: FORMTEXT      Worker NameDHS County or PAFC Provider 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 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.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. 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.Relative Signature/Relationship to ChildDateRelative Signature/Relationship to ChildDateWorker SignatureDate FORMCHECKBOX  I am not interested in pursuing licensure and understand that I may pursue licensure at any time. (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 SignatureDateDepartme,Ft F H J L ` b d n p r t     ( * , 6 8 : < P R T ^ ` b d ԷЬԷЙԷЎԷjhUjhUh8h^5j hUjhSUmHnHujhUhjhUh8h^CJ h8h^h^hrh5'hb-ha4vxsj $Ifgdr<kdX$$Ifl48'"4 laf4 $Ifgd5'<kd$$Ifl48'"4 laf4 $Ifgd5'yyB H J r i`` $Ifgd^Okd$$Ifl4 08'@ 4 laf4 $Ifgd^<kd$$Ifl48'"4 laf4   : b VMM $Ifgd^Okd$$Ifl4 08'@ 4 laf4 $Ifgd^Okd$$Ifl408'@ 4 laf4b d  F VMD $Ifgd^ $IfgdOkd$$Ifl4 08'@ 4 laf4 $Ifgd^Okdl$$Ifl408'@ 4 laf4      4 6 8 B D F H J ` b d f h | ~   " $ . 0 8 ׷ӬרӉ~vh8h^5j hUjH hUh8h^CJhe8 h8h^h^jhUh8hCJh8h5jhUh h8hjhSUmHnHujhUjphU.F H J b d f A8 $Ifgd{}Vkd $$Ifl4 08'@ 4 laf4p $Ifgd{} $IfgdVkd\$$Ifl408'`@ 4 laf4p  2 PGG $Ifgd{}Okd$$Ifl4 084'4 laf4 $Ifgd^Vkd2$$Ifl408'@ 4 laf4p 2 4 6 8 i] $$Ifa$gdf+<kd $$Ifl4 8'"4 laf4 $Ifgd^Okd0 $$Ifl4084'4 laf4 ]N($If^gdKOkd| $$Ifl4 08'hf!4 laf4 $$Ifa$gdK $IfgdK<kd $$Ifl48'"4 laf4 | atuTUcdeEpst h oh{}jhSUjh{}Uh{}h8h^5jhSUj`hSUjhSUjhSUjL hSU h5'hf+j hSUjhf+Uhf+0pDOkd $$Ifl4 08'hf!4 laf4 $$Ifa$gdK($If^gdKOkdd $$Ifl408'hf!4 laf4pqrstPDOkd4$$Ifl4 08'hf!4 laf4 $$Ifa$gdK($If^gdKOkd $$Ifl408'hf!4 laf4PQRSTfDOkd$$Ifl4 08'hf!4 laf4 $$Ifa$gdK($If^gdKOkd$$Ifl408'hf!4 laf4DOkd$$Ifl4 08'hf!4 laf4 $$Ifa$gdK($If^gdKOkdx$$Ifl408'hf!4 laf4ADOkdH$$Ifl4 08'hf!4 laf4 $$Ifa$gdK($If^gdKOkd$$Ifl408'hf!4 laf4ABCDEoJ> $$Ifa$gdf+Okd$$Ifl408'hf!4 laf4 $$Ifa$gdK $IfgdKOkd0$$Ifl408'hf!4 laf4opqrs]N($If^gdKOkdv$$Ifl4 08'hf!4 laf4 $$Ifa$gd{} $Ifgd{}<kd$$Ifl48'"4 laf4DOkd$$Ifl4 08'hf!4 laf4 $$Ifa$gd{}($If^gdKOkd^$$Ifl408'hf!4 laf4>Cajv9:HIJvw56DEF"#$%豬xjhf+Uhvha5jhSUjhaUhah8h^5 hv5 h^5hf+jhSUjZhSUjhSUjhSU h oh{}h{}jh{}UjFhSU/5DOkd.$$Ifl4 08'hf!4 laf4 $$Ifa$gd{}($If^gdKOkd$$Ifl408'hf!4 laf456789KrDOkd$$Ifl4 08'hf!4 laf4 $$Ifa$gd{}($If^gdKOkd$$Ifl408'hf!4 laf4rstuv1DOkd$$Ifl4 08'hf!4 laf4 $$Ifa$gd{}($If^gdKOkdr$$Ifl408'hf!4 laf412345GDOkdB$$Ifl4 08'hf!4 laf4 $$Ifa$gd{}($If^gdKOkd$$Ifl408'hf!4 laf4J> $$Ifa$gdf+Okd$$Ifl4p08'hf!4 laf4 $$Ifa$gdK $IfgdKOkd*$$Ifl408'hf!4 laf4%]N($If^gdvOkdp$$Ifl4 08'hf!4 laf4 $$Ifa$gdv $Ifgdv<kd$$Ifl48'"4 laf4JJ;($If^gdKOkd$$Ifl4 08'hf!4 laf4 $$Ifa$gdK $IfgdKOkdX$$Ifl408'hf!4 laf4NO]^_FGUVW LM[\]Kstxyz苃h^h5Sh^5 h^5j *hSUj(hSUjh'hSUj &hSUj$hSUjT#hSUj!hSUj hSUhf+jhf+Uj@hSU2JKLMN`BJ;($If^gdKOkd( $$Ifl4 08'hf!4 laf4 $$Ifa$gdK $IfgdKOkd$$Ifl408'hf!4 laf4BCDEFXJ;($If^gdKOkd!$$Ifl4 08'hf!4 laf4 $$Ifa$gdK $IfgdKOkd!$$Ifl408'hf!4 laf4{J? ($IfgdKOkd"$$Ifl4 08'hf!4 laf4 $$Ifa$gdK $IfgdKOkdl"$$Ifl408'hf!4 laf4{|}~ J? ($IfgdKOkd<$$$Ifl4 08'hf!4 laf4 $$Ifa$gdK $IfgdKOkd#$$Ifl408'hf!4 laf4     J? ($IfgdKOkd%$$Ifl4 08'hf!4 laf4 $$Ifa$gdK $IfgdKOkd$%$$Ifl408'hf!4 laf4HJ? ($IfgdKOkd&$$Ifl4 08'hf!4 laf4 $$Ifa$gdK $IfgdKOkd&$$Ifl408'hf!4 laf4HIJKL^J? ($IfgdKOkdP($$Ifl4 08'hf!4 laf4 $$Ifa$gdK $IfgdKOkd'$$Ifl408'hf!4 laf4GJ;($If^gdKOkd)$$Ifl4 08'hf!4 laf4 $$Ifa$gdK $IfgdKOkd8)$$Ifl408'hf!4 laf4GHIJKtyJAA $Ifgd(,Okd+$$Ifl4 08'hf!4 laf4 $$Ifa$gdK $IfgdKOkd*$$Ifl408'hf!4 laf4yzVOkd+$$Ifl4x08J'4 laf4 $IfgdfNOkd|+$$Ifl4x08J'4 laf4235/0456FGKLOWxyyyyyyyyͺͶh`X0JmHnHu* hG0JjhG0JUhGh(VUhh^aJhhb-j-hSUjhSUhS hS5 hv5j,hSUjh^Uh^h5Sh^5 h^53W<kdd-$$Ifl408'"4 laf4$  d$If^`a$gd5SOkdt,$$Ifl4x08J'4 laf405iOkd.$$Ifl4x08J'4 laf4 $IfgdfN<kdD.$$Ifl48'"4 laf456GLMNVI $If^gd5SOkd/$$Ifl4x08J'4 laf4 $IfgdfNOkd,/$$Ifl4x08J'4 laf4NOyyyyyyy(Pmhfddhb`=<gd{}<kd0$$Ifl48'"4 laf4$HH$If]H^Ha$gd+<kd$0$$Ifl48'"4 laf4 nt 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. 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MYINFO.ini DB@tUserInfoPhone P!\ MYINFO.ini DB@tUserInfoYourExt P!& MYINFO.ini DB@tUserInfoFaxAC P!( MYINFO.ini DB@tUserInfoFax P!* MYINFO.ini DB@tUserInfoOffice P!^ MYINFO.ini DB@tUserInfoAddress P!` MYINFO.ini DB@tUserInfoCity P!b MYINFO.ini DB@tUserInfoState P!d MYINFO.ini DB@tUserInfoZip P!f MYINFO.ini DB@tUserInfoCO P!h MYINFO.ini DB@tUserInfoDI P!j MYINFO.ini DB@tUserInfoSEC P!l MYINFO.ini DB@tUserInfoUN P!n MYINFO.ini DB@tUserInfoWKR P!p MYINFO.ini DB@tUserInfo Boss Name P!@ MYINFO.ini DB@tUserInfo Boss Title P!B MYINFO.ini DB@tGet user info from INI fileUserInfoName MYINFO.ini D%X' UserInfoTitle MYINFO.ini D%X' UserInfoAreaCode MYINFO.ini D%X' "UserInfoPhone MYINFO.ini D%X' $UserInfoYourExt MYINFO.ini D%X' &UserInfoFaxAC MYINFO.ini D%X' (UserInfoFax MYINFO.ini D%X' *UserInfoOffice MYINFO.ini D%X' ,UserInfoAddress MYINFO.ini D%X' .UserInfoCity MYINFO.ini D%X' 0UserInfoState MYINFO.ini D%X' 2UserInfoZip MYINFO.ini D%X' 4UserInfoCO MYINFO.ini D%X' 6UserInfoDI MYINFO.ini D%X' 8UserInfoSEC MYINFO.ini D%X' :UserInfoUN MYINFO.ini D%X' <UserInfoWKR MYINFO.ini D%X' >UserInfo Boss Name MYINFO.ini D%X' @UserInfo Boss Title MYINFO.ini D%X' B Update Form with user info WorkerName D%vG workerName  DB@xj WorkerTitle D%vG WorkerTitle  DB@xjWorkerAreaCode D%vGWorkerAreaCode " DB@xj WorkerPhone D%vG WorkerPhone $ DB@xjWorkerExtension D%vGWorkerExtension & DB@xjFaxAC D%vGFaxAC ( DB@xj WorkerFax D%vG WorkerFax * DB@xj Countynumber D%vG Countynumber 6 DB@xjDistrict D%vGDIstrict 8 DB@xjSection D%vGSECtion : DB@xjUnit D%vGUNit < DB@xjWorker D%vGWorker > DB@xj CountyName D%vG CountyName , DB@xj CoAddress D%vG CoAddress . DB@xjCoCity D%vGCoCity 0 DB@xjCoState D%vGCoState 2 DB@xjCoZip D%vGCoZip 4 DB@xjSupervisorName D%vGSupervisorName @ DB@xjSupervisorTitle D%vGSupervisorTitle B DB@xj. Update other Form Fields on Form & Exit Macro- Selected$=GetFormResult$ ("CurrentDate")! TheSerialDate = Today() + 14$ TheDate$ = Date$(TheSerialDate)& SetFormResult "DueDate", TheDate$) EditGoTo "CreateDate" : UnlinkFields EditGoTo "GranteefirstName"- ToolsProtectDocument .NoReset = 1, .Type = 2/ ToolsProtectSection .Section = 2, .Protect = 0d FileClose 2 SelectName = - 1kpoh`(Attribute VB_Name = "MyInfo" Public Sub Main(X) D.nDescription|Enter Personal rma:zProcDataIInvoke _FuncINoi8l..nADim iRet B  User$ATitleAreaCod-PhonYourExtFax|AC Offic $AddressCitByStat Zip ODILSEB;UN WKRBoss|| 'DEFINE DIALOG BOX WordBasic.BeginDialog 582, 300,} G TextBox 109@ A 5@ 18@ I @ey 56 * 83 _[ 105WDi 2A3321A5r 34 _  | 9 7 @ 1$55E [1 Pi 23` 6i`cV3jFAXAC41e lV1@,CO629 *DI7m pV? UN6z4!l1.yVm23n`~64`'Fz7,, c3z#the followin`g infa@bout ys0elf. ", ׂ !:w5f"bC #1z0@8O$351{1A-ST- u5 abm3r13@? gY  ;"C O-DI-T-U,N-@H47224*; supervisor!a 124f6p6iOKButtY48 8pR21 fCanctel3kEndn ҂dlg!u! As Object: Se$t = CurValues. vGET USER INFO FROMI FILE AND@ PUT I NTOzx.t[GetPrivfileS@@ng$](" "'P:qMY.ini"r hl ? pa"4??>? Mpn_1r &.nAC `axU/-Y??>OMA\C$$a&gp Op | DIpp/-UN0 | {p y QaserInfo", "Boss Name`MYINFO.ini") dlgU.Title = WordBasic.[GetPrivateProfileString$]("t| 'DISPLAY DIALOG BOX AND RESPOTO USER INPUT iRet Dialog.p (If 3-1 Then 'OK BUTTON ?WRI@TE NEW3FO6I FILE xSx wYour ?, - -AreaCod|PhonEExtE@FaxACL+@OfficZ|Address0$ L+gCity ? : |StP  z Zo%  CoCity  ! 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ClientStateD ClientState Uppercase1Enter the Addressee's 2 digit State Abbreviation. ClientZipD ClientZip UppercaseKEnter the Addressee's Zip Code (+4 if known) (Example: 48909 or 48909-7537)D CoAddress UppercaseaEnter the County's mail address (street address, PO Box, etc., where the mail will be delivered).D CoAreaCodeEnter the County's Area CodeDCoCity UppercaseEnter the County's City.D CoExtensiond8(OJQJ_HmH sH tH XOX CaseNumber1?d8(OJQJ_HmH sH tH XOX ClientCity1@d8(OJQJ_HmH sH tH ZOZ ClientState1Ad8(OJQJ_HmH sH tH ZO"Z ClientZip1BdtCJOJQJ_HmH sH tH VO2V CoAddress1Cd8(OJQJ_HmH sH tH XOBX CoAreaCode1 Dd`CJOJQJ_HmH sH tH PORP CoCity1Ed8(OJQJ_HmH sH tH ZObZ CoExtension1Fd8(OJQJ_HmH sH tH ^Or^ CoPhoneNumber1Gd8(OJQJ_HmH sH tH ROR CoState1Hd8(OJQJ_HmH sH tH ^O^ CoSuppaddress1Id8(OJQJ_HmH sH tH XOX CountyName1Jd8(OJQJ_HmH sH tH \O\ CountyNumber1 Kd`CJOJQJ_HmH sH tH ROR CoZip1LdtCJOJQJ_HmH sH tH NON Date11 Md`CJOJQJ_HmH sH tH TOT District2 Nd`CJOJQJ_HmH sH tH LOL FaxAC Od`CJOJQJ_HmH sH tH VOV FirstName1Pd8(OJQJ_HmH sH tH XOX FirstName21Qd8(OJQJ_HmH sH tH `O"` GranteeAddress1 Rd`CJOJQJ_HmH sH tH \O2\ GranteeCareof Sd`CJOJQJ_HmH sH tH XOBX GranteeCity Td`CJOJQJ_HmH sH tH `OR` GranteeClientID Ud`CJOJQJ_HmH sH tH dObd GranteeFirstName2 Vd`CJOJQJ_HmH sH tH bOrb GranteeLastName1Wd8(OJQJ_HmH sH tH ZOZ GranteeState Xd`CJOJQJ_HmH sH tH VOV GranteeZip Yd`CJOJQJ_HmH sH tH TOT LastName1Zd8(OJQJ_HmH sH tH VOV LastName21[d8(OJQJ_HmH sH tH ROR OtherID1\d8(OJQJ_HmH sH tH ROR Section2 ]d`CJOJQJ_HmH sH tH ^O^ SuperAreaCode1 ^d`CJOJQJ_HmH sH tH `O` SuperExtension1_d8(OJQJ_HmH sH tH dOd SuperPhoneNumber1`d8(OJQJ_HmH sH tH `O` SupervisorName1ad8(OJQJ_HmH sH tH LO"L Unit2 bd`CJOJQJ_HmH sH tH PO2P Worker2 cd`CJOJQJ_HmH sH tH `OB` WorkerAreaCode1 dd`CJOJQJ_HmH sH tH bORb WorkerExtension1ed8(OJQJ_HmH sH tH TObT WorkerFax fd`CJOJQJ_HmH sH tH XOrX WorkerName1gd8(OJQJ_HmH sH tH \O\ WorkerName2hd8(5OJQJ_HmH sH tH ZOZ WorkerPhone1id8(OJQJ_HmH sH tH ^O^ WorkerTitle1jd8(5OJQJ_HmH sH tH LOL Emailkd8(OJQJ_HmH sH tH  @0 0Address1BureauCareOf CaseNumber ClientCity ClientState ClientZip CoAddress CoAreaCodeCoCity CoExtension CoPhoneNumber CoState CoSuppaddress CountyName CountyNumberCoZipDate1DistrictEmail/FaxAC FirstName FirstName2GranteeAddress1 GranteeCareof GranteeCityGranteeClientIDGranteeFirstNameGranteeLastName GranteeState GranteeZipLastName LastName2OtherID Section! SuperAreaCode"SuperExtension#SuperPhoneNumber$SupervisorName%Unit&Worker'WorkerAreaCode(WorkerExtension) WorkerFax* WorkerName+ WorkerName2, WorkerPhone- WorkerTitle.0Address1BureauCareOf CaseNumber ClientCity ClientState ClientZip CoAddress CoAreaCodeCoCity CoExtension CoPhoneNumberCoState CoSuppaddress CountyName CountyNumberCoZipDate1DistrictFaxAC FirstName FirstName2GranteeAddress1 GranteeCareof GranteeCityGranteeClientIDGranteeFirstName1GranteeLastName GranteeState GranteeZipLastName LastName2OtherIDSection SuperAreaCodeSuperExtensionSuperPhoneNumberSupervisorNameUnitWorkerWorkerAreaCodeWorkerExtension WorkerFax WorkerName WorkerName2 WorkerPhone WorkerTitleUser Input 10pt(<Pdu$5I]n  4EYm(<Pdx y:f,B$,7=EFGKL b F 2 pPAo5r1JB{ HGy5NPB !"#%&'()*+-./012345689:;DJB  &(4:<HNP\bdpsu"$035AGIU[]ilnz   ,24@CEQWYekmy"&(4:<HNP\bdpvxFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF0Address1BureauCareOf CaseNumber ClientCity ClientState ClientZip CoAddress CoAreaCodeCoCity CoExtension CoPhoneNumberCoState CoSuppaddress CountyName CountyNumberCoZipdate1DistrictEmailFaxAC FirstName FirstName2GranteeAddress1 GranteeCareOf GranteeCityGranteeClientIDGranteeFirstNameGranteeLastName GranteeState GranteeZipLastName LastName2OtherIDSection SuperAreaCodeSuperExtensionSuperPhoneNumberSupervisorNameUnitWorkerWorkerAreaCodeWorkerExtension WorkerFax WorkerName WorkerName2 WorkerPhone WorkerTitle)=Qev%6J^o !5FZn)=Qey  !"#$%&'()*+,-./';Oct#4H\m 3DXl';OcwYq@{(UnknownGz Times New Roman5Symbol3& z Arial?5 z Courier New5& zaTahoma9 Webdings;Wingdings"h0@?Yq