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HSACS 534 Paid Alternative Care Request

** FORM MUST BE SUBMITTED NO LATER THAN 1 WEEK BEFORE ALTERNATIVE CARE.

** IF USING MORE THAN ONE CARE PROVIDER, PLEASE USE SEPARATE FORMS

Today's Date

Email of Requestor

I am applying for alternate care funds to be paid to:

Myself for a family vacation inclusive of my foster child(ren). (“Inclusive Respite”)

A licensed foster parent to care for my foster child(ren) in my absence. (“Paid Alternative Care”)

Other approved alternate care provider (direct care staff, babysitter, or licensed child care staff).

Alternate Care Giver Phone Number

Do you have another child to add?

Yes

2 Do you have another child to add?

Yes

3 Do you have another child to add?

Yes

4 Do you have another child to add?

Yes

5 Do you have another child to add?

Yes

Foster Parent Signature

First Name

Last Name

Choose how to sign

Draw Type

In selecting the care provider, I have considered the unique needs and behaviors of each child and have communicated the supervision requirements to maintain child safety. All medical, dental, and therapeutic appointments, as well as visitation and school transportation, have been arranged and covered. I have discussed these arrangements with the child’s caseworker and have verified the care provider is in good standing with licensing and/or the child’s caseworker and able to accommodate the additional children.