1. a) The title, which will be: "Relative Caregiver Application Form for Certification".

2. b) An explanatory introduction, which will contain the following text:

   "You have been identified as a relative of a child who needs placement. You are receiving this application to begin the certification process for a related child to be placed with you. We consider any adult with a meaningful relationship to the child a family member (or "relative"), even if you are not related by blood or marriage.

   Our agency is committed to ensuring a safe environment for the child and this means considering everything we can about whoever cares for them while they are separated from their home. In addition to ensuring child safety, getting certified as a relative caregiver has benefits for your household such as:

   Government funds to assist with expenses

   Service referrals to support the child

   Power as a decision maker for the child, with the ability to:

   Enroll the child into your local school district

   Work directly with the child's doctors (pediatrician, dentist, etc.)

   Give input on when and how the child interacts with their previous caregivers until they are able to reunite

   The application to become a formal relative caregiver includes all of the following checks:

   Home assessment to make sure your home is safe for the child, completed by the caseworker while you are present

   Caregiver assessment to make sure you're able to care for the child

   Criminal background records, including fingerprinting for any person 18 and older

   Child abuse and neglect records for any person 13 and older

   Sex offender registry records for any person 13 and older

   To complete the criminal background check you will need to show an ID, like a driver's license or passport. Refer to the fingerprinting ID form for more information. If you have a social security number or tax ID number (ITIN), you will need to provide it on the Authorization for Background Check for Certified Relative Homes Form.

   Talk with your caseworker if you need these forms in a different language, accommodations for a disability, or do not understand something for any reason. Your caseworker will refer you to resources, including the opportunity to connect with other relative caregivers.

   We recognize that this process looks into highly sensitive information about you, your past, and your home. For instance, even if you have a record, the agency might be able to approve you, so long as there is proof that it will not affect the child's safety and well-being.

   Thank you for going through this application process and offering a home for your family member."

3. c) A section entitled "Instructions", which will contain the following text:

   1. d) A section entitled "Section 1: Relative Caregiver Applicant Information", which will request the following information for each applicant:
   2. 1) First name;
   3. 2) Middle name;
   4. 3) Last name;
   5. 4) Gender (how they identify);
   6. 5) Race or ethnicity (how they identify);
   7. 6) Tribal affiliation (if any);
   8. 7) Email;
   9. 8) Cell phone;
   10. 9) Work phone;
   11. 10) Home phone;
   12. 11) Current address;

   13. 12) Mailing address; and

       1. 13) Whether a language other than English is spoken and if so what language and proficiency (bilingual, fluent, conversational).
   14. e) A section entitled "Section 2: Child Information", which will request the following information for each child a relative is seeking to become a certified relative caregiver for:
   15. 1) First Name;
   16. 2) Middle name;
   17. 3) Last name;
   18. 4) Date of birth;

   19. 5) Gender;

       1. 6) Race or ethnicity;
       2. 7) Tribal affiliation (if any); and
       3. 8) Relationship to caregiver (Applicant 1).
       4. f) A section entitled "Section 3: Other Persons Living in the Home", which will include the following information for each other person living in the home:
       5. 1) Name;
       6. 2) Relationship; and
       7. 3) Date of Birth.

       8. g) An agreement section with the following declaration: "I, the undersigned, hereby apply for certification as a relative caregiver. I declare that I:

          1. 1) Have received a copy of the standards for certified relative homes, have read them and are familiar with them.
          2. 2) Will be subject to and cooperate with the supervising agency in the certification process to determine my compliance with certification standards.
          3. 3) Will be subject to supervision in terms of ongoing conformance with certification standards upon approval as a certified relative home."
          4. 4) The declaration shall have places for the applicant to sign and date.

   This form is used to apply to get certified as a formal relative caregiver. If you have any questions about this form, please contact your caseworker for assistance. Please print clearly when completing this form. Questions about gender, race, and ethnicity are collected for statistical purposes.

To be considered to become a certified relative caregiver, a relative shall complete an application form. Only a Department-issued official form with a CFS number in the top left-hand corner shall satisfy the requirements of 225 ILCS 10/3.4 and this Part. The form shall consist of the following elements: