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Lucas County Children Services Foster Care and Adoption Inquiry Form

Date and Time:
12/4/2008 3:43:32 PM

Applicant Name:


Applicant Address:


Applicant City:


Applicant State:


Zip:


County of Residence (if Ohio Resident)


DayTime Phone:


Evening Phone:


Cell Phone:


E-mail Address:


Federal law requires that we collect information about the race or culture of people who inquire about foster parenting or adoption. This information is not used in any way to determine your eligibility as a foster or adoptive parent, and you are not required to answer. If you choose to give this information, which of the following describes your race or culture (select one):

Caucasian
African-American
Bi-racial
Other
Prefer not to answer


Are you interested in:

Foster Care
Adoption
Both
Unknown

If you are interested in specific child(ren) for adoption, please provide name(s):

Any other questions, comments or information:


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Toledo, OH  43604

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