Please complete this application if you are interested in volunteering as a Parent Liaison for the 2020-2021 contract year. Name* First Last Date* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Alternative PhoneEmail* In case of emergency contact:* Phone*Complete this section if you are or were a New Jersey licensed resource parentWhat is the status of your home with DCP&P? Open Closed License Number: Approximately how long have you been a licensed resource parent in NJ Type of Home (check all that apply) Kinship Provider Resource Family Adoptive Home I provide or have provided care to children with the following characteristics (check all that apply) Infants (0-2 Years) Early childhood (3-5 Years) Childhood (6-11 Years) Early Adolescents (12-15 Years) Late Adolescents (16+ Years) Child(ren) with child(ren) Sibling group A child with medical needs A child with mental health/behavioral needs I agree that the information submitted in this application is true and correct to the best of my knowledge. I understand that volunteer applications for the Connecting Families Program may be reviewed and verified by the Department of Children and Families.* I agree Δ
