City of Hampton-Foster Grandparent Program

Application for Volunteer Service
as a Foster Grandparent

All fields marked with * are required.

Reference A
*Full Name:
*Birth Date:
*E-mail Address:
*Address:
*City:	State: Zip:
*Phone Number:	*Members in Household:

Explain arrests, indictments and convictions for law violations (other than minor traffic offenses):
Have you ever had a founded complaint of child abuse made against you? If so, give the dates, location, and circumstances. Have you ever been investigated but not founded for child abuse? If so, please give the dates, location, and circumstances:
(Failure to reveal any arrests, convictions, or indictments will result in immediate termination. Any convictions, arrests, or indictments will not necessarily prevent an applicant from becoming a Foster Grandparent.)
*Highest Level of Formal Schooling:
Specialized training (describe):
Describe any experience you have in working with children in organized programs or schools:
Full Name:
Address:
City:	State: Zip:
Phone Number:
Reference B
Full Name:
Address:
City:	State: Zip:
Phone Number:
Reference C
Full Name:
Address:
City:	State: Zip:
Phone Number:

Comments: