Foster Grandparent Application

General Information

First Name *
Last Name *
Address *
Apartment #
City *
State *
Zip *
Phone *
Email *
Date of Birth *
mm/dd/yyyy
Marital Status *

Primary Care Physician

Name
Address
Phone

Emergency Contact

Name
Address
Phone
Name
Address
Phone

Excess Liability Insurance

If hired, whom would you like to name as beneficiary under the Foster Grandparent Program's Excess Liability Insurance? (Person must be at least 18 years of age).

First Name
Last Name
Address
City
State
Zip

Income Sources and Amount Per Month

Applicant's Monthly Social Security
Pension
Rent Paid to You
Interest Income
Additional Income
Food Stamps
Total Monthly Income
Total Annual Income
Please select any that you receive
# of people in household
# dependent on your income

Transportation

What mode of transportation would you use to get to your work site?
Select all that apply.

Additional Information

Please explain why you wish to be a Foster Grandparent Program Volunteer *
Please describe any experience you have with children, tutoring or mentoring
What languages can you speak and/or translate?
Have you ever served in the military?
Which branch did you serve in?

Character Reference

Name
Address
Phone
Name
Address
Phone

Please Read Carefully

Placement in the Foster Grandparent Program is contingent on the outcome of the Online Sex Offender Search, the Criminal Background Check, the PA Child Abuse Background Check and the FBI Fingerprinting Check. Applicants have the right to challenge the outcome of their Background Checks if they feel they are inaccurate. 

If an applicant meets all of the requirements for the program and continues on with training, a physicl will be required. All FGP physicals are done by Concentra Urgent Care at no cost to the applicant.

I acknowledge that I have read and understand the above information.