Foster Care/Adoption Inquiry Form

Please take a moment to complete the following information, and we will send you additional information about becoming a foster/adopt parent through Clermont County Children's Services.

Items with a "*" next to them are required fields.

Inquiring about: *

Parent #1 First Name: *
Parent #1 Last Name: *
Parent #1 Date of Birth: *
Ethnicity/Race: *	If other, please specify

Parent #2 First Name:
Parent #2 Last Name:
Parent #2 Date of Birth: *
Ethnicity/Race: *	If other, please specify

Other Names
(maiden, etc.):

Street Address: *
City: *
State: *
Zip: *

Home Phone:
Work Phone (Parent#1):
Work Phone (Parent#2):
Email Address:
Alternate Email:

OPTIONAL INFORMATION

Where did you hear about Clermont County's Foster Care & Adoption Program?

Radio Ad News Story Billboard
Radio Program Other Foster Parent Community Event
TV Ad Other Adoptive Parent Internet
TV Program Poster Other
Newspaper Ad

If other, please specify:

Comments: (Max: 200 characters)

If you have additional questions, please feel free to call the number below or send e-mail to Clermont County Children's Services staff.

Clermont County Children's Services
Foster Care Program Recruiter
(513) 732-7173

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