5300 FormB

OFFICE OF CHILDREN AND FAMILY SERVICES

Instructions:
Prospective Emergency Foster Parent(s): Complete, sign, and date this statement
Caseworker: Sign and date this statement

Parent1 First Name

Parent1 Last Name

Parent1 Middle Initial

Parent1 Relation to Child

Parent1 City

Parent1 Address

Parent1 State

Parent1 Zip Code

Parent2 First Name

Parent2 Last Name

Parent2 Middle Initial

Parent2 Relation to Child

Parent2 City

Parent2 Address

Parent2 State

Parent2 Zip Code

Initial

PROSPECTIVE EMERGENCY FOSTER PARENT’S SIGNATURE

Date

PROSPECTIVE EMERGENCY FOSTER PARENT’S SIGNATURE

Date

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