DEPARTMENT OF CHILDREN AND FAMILIES Division of Safety and Permanence CONSIDERATIONS FOR REASONABLE AND PRUDENT PARENTING Use of form: The information contained in this form must be provided to the out-of-home care provider when the is placed with the out-of home care provider. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. If additional space is needed when completing this form, attach additional sheet(s). I. GENERAL INFORMATION Date Form Filled Out (mm/dd/yyyy) Date Child Placed in Out-of-Home Care (mm/dd/yyyy) A. Child Information Name (Full Nicknames(s) Birthdate (mm/dd/yyyy) – Race Ethnicity Social Security Number Gender Female Male Other Primary Language Second Language Third Language Tribal Affiliation or Membership Spiritual or Religious Affiliation Child or Family Preferred Place of Worship – II. ALL ABOUT ME The child or youth should complete this section, if they would like to. Completion of this section is not required. In my free time I like to (i.e. play sports, hang out with friends, visit family, play games, go outside, etc.): My best friends are: Some of my favorite foods and meals are: Some foods and meals I really dislike are: Some of my favorite books, stories, and movies are: I am closest to the following family members: I am close to these other important adults: I am in the following clubs, sports, and activities: I work at or would like to work at (this can include babysitting, lawn mowing, and more formal employment): My pets are: I like to be alone when: At night before going to bed, my favorite thing to do is: The thing that scares me the most about foster care is: Things I like about my family are: I think it’s important that you know the following about me: More than anything I hope:
DEPARTMENT OF CHILDREN AND FAMILIES Division of Safety and Permanence CONSIDERATIONS FOR REASONABLE AND PRUDENT PARENTING Use of form: The information contained in this form must be provided to the out-of-home care provider when the is placed with the out-of home care provider. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. If additional space is needed when completing this form, attach additional sheet(s). I. GENERAL INFORMATION Date Form Filled Out (mm/dd/yyyy) Date Child Placed in Out-of-Home Care (mm/dd/yyyy) A. Child Information Name – (Full Birthdate (mm/dd/yyyy) Nicknames(s) Race Ethnicity Social Security Number Gender Female Male Other Primary Language Second Language Third Language Tribal Affiliation or Membership Spiritual or Religious Affiliation – Child or Family Preferred Place of Worship II. ALL ABOUT ME The child or youth should complete this section, if they would like to. Completion of this section is not required. In my free time I like to (i.e. play sports, hang out with friends, visit family, play games, go outside, etc.): My best friends are: Some of my favorite foods and meals are: Some foods and meals I really dislike are: Some of my favorite books, stories, and movies are: I am closest to the following family members: I am close to these other important adults: I am in the following clubs, sports, and activities: I work at or would like to work at (this can include babysitting, lawn mowing, and more formal employment): My pets are: I like to be alone when: At night before going to bed, my favorite thing to do is: The thing that scares me the most about foster care is: Things I like about my family are: I think it’s important that you know the following about me: More than anything I hope: