LBCC - Foster and Kinship Care Education Ptogram

Personal Information

Legal Last Name: *

Legal First Name: *

Middle Name:

Primary Language/Secondary Language: *

Address: *

County of Residence: *

Home Phone:

Cell Phone: *

E-Mail Address: *

Preferred Method of Contact (Pick One) * Home Phone Cell Number E-mail Address

Applicant

Are you an Approved Resource Parent or Resource Family Applicant?* Yes No

Release Statement

This statistical information will be used to keep accurate records of the services provided by the community college Foster and Kinship Care Education Program. This information will assist the college in keeping accurate records of the classes that you take. It will also help the college to keep you informed of upcoming classes and events within the FKCE program at your local community college. Your name, address, phone number and partial social security number will remain confidential. Statistical data may be reported to funding agencies. No unauthorized person will have access to your information.

* I am aware that I am consenting for Long Beach City Community College District's Foster Care Program to share via electronic means and/or mail, my FKCE workshop attendance transcript and certificates, that maintain record of all my community college FKCE workshop trainings, to the Department of Children and Family Services, Probation Office, and/or the Foster Family Agency that I maintain a foster care contract.

Include your social workers's information *

Check this box if you would like to be notified of future FKCE classes offered at this college and/or other related events