1. (a) The applicant shall complete and submit an application packet that includes the following:

   1. (1) The completed Form 1715 “Application for Foster Family Care License” (October 2023 edition) acknowledging that:

      1. a. “I/we have reviewed the Administrative Rule He-C 6446 and will adhere to the rules if I/we are licensed as a Foster Family Care provider. I/We authorize the NH Division for Children, Youth and Families (DCYF) to receive the results of the central registry check, the state registry check, and the out-of-state child abuse and neglect registry checks.”;

      2. b. “I/We understand that:

         The Division for Children, Youth and Families examines its child abuse records and the criminal conviction records of the State Police on Adoptive/Foster Parent applicants (RSA 170-E:29), or may revoke, or refuse the license of any provider who furnishes, or makes any misleading, or false statement, or report to the Division (RSA 170-E:35, V);

         All household members 18 years and older shall be subject to a criminal records search through the NH state and local police, and through all other states in which the individual has resided for the preceding 5 years;

         All household members 18 years old or older shall be subject to a Federal Bureau of Investigation fingerprint record check;

         Information shared about a foster child’s safety, the caregiver’s safety and the appropriateness of the placement, is confidential (RSA 170-E:49);

         Other information about the child’s family, or the circumstances of the child’s placement, must also be kept confidential. This information was taken from DCYF care records and files whose confidentiality is protected by federal law. Federal regulations (42 CFR, Part 2) prohibit the further sharing of this information without obtaining the written consent of the individual to whom it pertains, or as otherwise permitted by federal regulations;

         Completion of this application does not constitute acceptance into the foster care family program. It is a statement of intention only and may be withdrawn at any time; and

         DCYF has the right to verify information contained in this application.”; and

      3. c. “I/We understand the above statements and verify that all statements made are true.” ;
   2. (2) The Form 1720 “Fire Department Inspection – One and Two Family Dwelling” (June 2020 edition) or Form 1720A “Fire Department Inspection – Apartment Building” (June 2020 edition) as applicable, completed in accordance with He-C 6446.09(f);
   3. (3) The Form 1721 “Home Health Inspection” (June 2020 edition) completed in accordance with He-C 6446.09(g);

   4. (4) The completed Form 1717 “Local Law Enforcement Check” (June 2020 edition) and the applicable Criminal History Record Information form as identified in Table 5700-1 in Saf-C 5703, authorizing the licensing agency to conduct a criminal records check and local law enforcement check for, the foster parent requesting renewal and all household members 18 years or older, certifying:

      1. a. “I/We agree to provide any further information, which may be required in reference to my/our past record. I/We also authorize and request every person, firm, company, corporation, governmental agency, court, association or institution having control of any documents, records or other information pertaining to me/us, to provide to the Division for Children, Youth and Families or Child-Placing Agency any such information including documents, records, or files regarding charges or complaints filed against me/us, formal or informal, pending or closed or other pertinent data and to permit the Division or any of its agents to inspect and make copies of such records.”;
      2. b. “I/We hereby release, discharge, and exonerate the Division for Children, Youth and Families, its agents and representatives, and any persons so furnishing or inspection of such documents, records or other information or the investigation made by or on behalf of the Division for Children, Youth and Families.”; and
      3. c. “I hereby agree to the release of information to the Division for Children, Youth and Families, its agents and representatives.”;

   5. (5) Form 2501 “NH Child Abuse and Neglect Central Registry Name Search Authorization Release of Information to Third Party” (June 2020 edition) completed by the foster parent requesting renewal and all household members 18 years of age or older authorizing the licensing agency to conduct a central registry check certifying:

      1. a. “I acknowledge that the results of this search can only be released to myself or a Child-Placing Agency pursuant to NH RSA 170-E, the Department of Health and Human Services pursuant to NH RSA 17-G:8-c, or another state’s Child Welfare Agency or Private Adoption Agency pursuant to NH RSA 169-C:35. I understand and authorize the results of this search to be provided to the person/agency listed below if in compliance with the aforementioned laws. Any entity listed below that is not governed under these laws will not be sent the results.”; and
      2. b. “I authorize the below named agency to receive the results of my registry check. I understand that the results will not be sent to me.”; and

   6. (6) For those applicants and household members 18 years of age or older who have lived outside the state of New Hampshire within the past 5 years of application:

      1. a. The results of a state criminal history records search for each state resided in, as required by He-C 6446.07; and
      2. b. The results of the child abuse and neglect registries for each state resided in, as required by He-C 6446.08.

2. (b) Each applicant shall provide the following autobiographical information:

   1. (1) A description of the applicant’s physical and mental health;
   2. (2) A brief history of the applicant’s childhood and family background including identification of family members, noting those family members with whom the applicant had a close relationship, and a description of the interactions between family members;
   3. (3) A description of the methods of discipline used in the applicant’s family;
   4. (4) The applicant’s childhood memories of enjoyable periods of time, events, and positive relationships;
   5. (5) The applicant’s present contacts with family members;
   6. (6) The educational background, including highest degree attained, and areas of training and expertise;
   7. (7) The employment history for the last 5 years;
   8. (8) A description of the applicant’s marital status and history, including previous marriages and divorces, if applicable;
   9. (9) A description of the applicant’s experience, if any, caring for children with special needs;
   10. (10) A description of criminal convictions and domestic violence petitions or restraining orders, if any;
   11. (11) A description of the foster home and the neighborhood where the applicant(s) resides;
   12. (12) A description of life in the applicant foster home, including the routine for housekeeping chores, and identification of any pets in the home, if applicable;

   13. (13) A description of the way in which the members of the applicant foster family:

       1. a. Solve problems;
       2. b. Settle disputes;
       3. c. Show love and affection;
       4. d. Show anger;
       5. e. Show sadness; and
       6. f. Share household chores;
   14. (14) A description of the family activities of the applicant foster family;
   15. (15) A description of the expectations, hopes, and fears of the applicant foster family; and
   16. (16) The applicant’s history of parenting other people’s children.

3. (c) Each additional adult caregiver residing in the foster home shall provide the following autobiographical information:

   1. (1) A description of the adult caregiver’s physical and mental health;
   2. (2) A brief history of the adult caregiver’s childhood and family background including identification of family members, noting those family members with whom the applicant had a close relationship, and a description of the interactions between family members;
   3. (3) A description of the methods of discipline used in the adult caregiver’s family;
   4. (4) The adult caregiver’s childhood memories of enjoyable periods of time, events, and positive relationships;
   5. (5) The adult caregiver’s present contacts with family members;
   6. (6) The educational background, including highest degree attained, and areas of training and expertise;
   7. (7) The employment history for the last 5 years;
   8. (8) A description of the adult caregiver’s marital status and history, including previous marriages and divorces, if applicable;
   9. (9) A description of the adult caregiver’s experience, if any, caring for children with special needs;
   10. (10) A description of criminal convictions and domestic violence petitions or restraining orders, if any;
   11. (11) A description of the applicant foster home and the neighborhood where the adult caregiver resides;
   12. (12) A description of life in the applicant foster home, including the routine for housekeeping chores, and identification of any pets in the home, if applicable;

   13. (13) A description of the way in which the members of the applicant foster family:

       1. a. Solve problems;
       2. b. Settle disputes;
       3. c. Show love and affection;
       4. d. Show anger;
       5. e. Show sadness; and
       6. f. Share household chores;
   14. (14) A description of the family activities of the applicant foster family;
   15. (15) A description of the expectations, hopes, and fears of the applicant foster family; and
   16. (16) The adult caregiver’s history of parenting other people’s children.

4. (d) An application shall be deemed complete upon submission of the application packet in (a) above, the autobiographical information in (b) and (c) above, and the following:

   1. (1) Form 1722 “Medical Information Statement” (October 2023 edition) completed in 2 parts, the first by the applicant or household member and the second by a physician, physician assistant, or nurse practitioner, for each applicant and each household member, and submitted by the completing physician, physician’s assistant, or nurse practitioner to include:

      1. a. Section 1, signed and dated by the applicant, household member, or authorized legal representative with the following acknowledgements:

         “By signing below, I authorize the following named healthcare provider to release my PHI listed below and any other information required by the assessment and evaluation and findings requested on this form, specifically the disclosure of any PHI that may be specified in Section 2 of this form, to the above named licensing agency and the department of health and human services, division for children, youth and families. I understand I am not required to sign this form, however, if I do not sign, the healthcare provider will not share my PHI included in the medical evaluation and assessment, and the licensing agency will not be able to process my application.” and

         “I understand that the department of health and human services, division for children, youth and families, and the licensing agency may use the disclosed information to the extent permitted by state and federal law and may no longer be protected by the HIPAA federal privacy rule (45 CFR Part 164.508(c)). I understand I can revoke my permission at any time by writing to the licensing agency. This authorization will expire 2 years from the date I sign below.”; and

      2. b. A copy of the child’s immunization record;
   2. (2) Form 1728 “Pre-Adoptive and Foster Family Care Financial Statement” (June 2020 edition);

   3. (3) The names and contact information for 5 references, in accordance with the following:

      1. a. Each reference shall be a person who has known the applicant(s) for more than one year;
      2. b. Of the 5 references, no more than one shall be from a person related to the applicant(s) by blood or marriage;
      3. c. All 5 references shall be positive in order to constitute a complete application for licensure; and
      4. d. All references received shall become a permanent part of the foster home record and as such shall be transferred to another child-placing agency if applicable;
   4. (4) For any foster home in which the applicant is not the homeowner, a letter of good standing shall be obtained and submitted from the proprietor of the property or his or her designee;
   5. (5) Completed home visits in accordance with He-C 6446.10;
   6. (6) A completed home study as described in He-C 6446.11; and
   7. (7) Proof of completion of pre-licensing training in accordance with He-C 6446.12.
5. (e) Upon receipt of the information requested in (a)-(d) above, the department shall review, notify, approve, or deny the application in accordance with RSA 541-A:29.
6. (f) If the information provided on the “Medical Information Statement” is incomplete or contradictory to other information provided by the applicant and the applicant is unable to provide information to resolve the conflict, the licensing agency shall require that the applicant or household member obtain a medical or psychological evaluation.
7. (g) Upon the request of the licensing agency, the applicant shall provide additional information and references if more information is required to assess the character and abilities of the applicant.
8. (h) A licensing agency that is not DCYF shall use the forms described in this section, except that they may alter the forms by adding the agency’s name, logo, and contact information.

Source. #7184, INTERIM, eff 12-28-99, EXPIRED: 4-26-00 New. #7321, eff 7-22-00; ss by #8663, eff 6-16-06; ss by #10788, eff 2-21-15 (from He-C 6446.04); ss by #13056, eff 6-16-20 (formerly He-C 6446.07); ss by #13790, eff 10-21-23