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Resource Family Applicant
Registration/Update Form
(CY131 01/05)

Instructions for the registering agency completing the CY131 01/05 are detailed below. After completing the form, please mail to:

Pennsylvania Adoption Exchange
P.O. Box 4569
Harrisburg PA 17111-0469
Questions should be directed to 1-800-227-0225

Completing the Form

Registering Agency

  1. Indicate by checking the appropriate boxes at the top of the form whether the information recorded is for a new registration or an update of existing information.
    1. If a new registration, check New Registration.
      1. Check the boxes for Adoption, Foster Care and/or Kinship (formal kinship care) to identify the type(s) of care the family wishes to provide.
    2. If an update of existing information, check Update.
      1. If needed, check the boxes for Adoption, Foster Care and/or Kinship (formal kinship care) to indicate any changes to the type(s) of care the family wishes to provide.
  2. Record the original PAE ID number in the Registration Update box.
  3. The registering agency completes the contact information, including:
    1. Agency Full Name
    2. Contact Person
    3. Mailing Address
    4. Email
    5. City
    6. State
    7. Zip Code
    8. County
    9. Telephone Number

Applicant Information (applicant completes and returns to agency)

Under the new requirements, all applications already registered with the Pennsylvania Adoption Exchange or the Foster Parent Registry must be updated by completing the shaded information and any changes to the original registration. The entire section must be completed for new applicants.

  1. Information required for updates includes:
    1. Applicant’s full name, date of birth, social security number
    2. Second applicant’s (if applicable) full name, date of birth, social security number.
    3. Any information that has changed since the original application.
  2. Information required for new registrations includes:
    1. The information detailed in 1 above.
    2. Gender
    3. Maiden Name
    4. Marital Status. Choices are:
      1. Married
      2. Single
      3. Widowed
      4. Divorced
      5. Separated
      6. Alternative Lifestyle
    5. Race / Ethnicity (check all that apply). Choices are:
      1. American Indian/Alaskan Native
      2. Asian
      3. Black/African American
      4. Native Hawaiian/Other Pacific Islander
      5. White
      6. Ethnicity: Hispanic

        7. NOTE: Hispanic MUST be checked as either Yes or No. If Hispanic is checked Yes, the appropriate race(s) must also be selected.

    6. Current Mailing Address
    7. Family Email Address (optional)
    8. Telephone Number
    9. City
    10. State
    11. Zip Code
    12. County

Previous Address

The registering agency must record the full home address, including county, for each residence in which the applicants have lived in the past 10 years.

  1. A separate page should be attached, if necessary.
  2. Check the Not Applicable box if the family’s only address for the past 10 years is the one already recorded in the Applicant Information section.

All Members of Household (attach additional page, if needed)

All members of the household, including those over 18 years of age, must be listed in this section. Additional pages may be attached, if needed.

Check the Not Applicable box if the household has no members other than the applicant.

NOTE: Children in the custody of a county children and youth agency placed in the home do not need to be listed in this section.

Information required for each household member is:

  1. Name
  2. Date of Birth
  3. Gender
  4. Relationship to Applicants
  5. Social Security Number

Update Information on Adult Household Members

This section is completed ONLY when updating adult household member information. Updates must be completed within 30 days of the registering agency receiving information about a change in household composition. If this section is completed, the shaded sections in the Applicant Information section on page 1 of the form must also be completed.

Adult household members are considered to be those age 18 and older. Check the Not Applicable box if there are no household members to add or delete.

NOTE: Children in the custody of a county children and youth agency placed in the home do not need to be listed in this section.

  1. For all adult members of the household, record any change in Marital Status, indicating the previous status in From: and the current status in To:
  2. Record any Change in Name information, with the original name in From: and the current name in To:
  3. Record any current household members not included in the original application in the Add: (Name) section. Information required is:
    1. Name
    2. Date of Birth
    3. Gender
    4. Relationship to Applicant
    5. Social Security Number
  4. If household members previously listed on an application no longer live in the household, please record them in the Delete:(Name) section. Information required is:
    1. Name
    2. Date of Birth
    3. Gender
    4. Relationship to Applicant
    5. Social Security Number

Registering Agency Disposition (Agency completes and returns to registry)

The registering agency reports the current status of the application by completing the appropriate section from the four available choices of Pending/Approved, Family Withdraws, Disapproved or Closure.

  1. Pending/Approved

    2. If the application is currently Pending or Approved, indicate by checking the appropriate box.

    1. If a foster or kinship (formal kinship care) family’s application is still pending when the record is updated, check the box for Pending.
    2. If a foster family, adoptive family or kinship (formal kinship care) family application is approved, check the box for Approved.
      1. Record the date of the approval.
      2. For foster family or kinship (formal kinship care)family, if full approval was granted, check the box for Full.
      3. If approval for a foster family or kinship (formal kinship care) family was granted on the basis of a regulatory waiver, check the box for Regulation Waiver Granted.
  2. Family Withdraws

    3. If the family withdraws from the agency, check the Family Withdraws box.

    1. Record the date the family withdraws.
    2. Record the reason the family withdraws. Reasons for a family withdrawing an application may include but are not limited to: pregnancy, separation or divorce, taking a break, etc.
  3. Disapproved

    4. If the family is disapproved, check the Disapproved box.

    1. Record the date of the disapproval.
    2. Record the reason for the disapproval by checking the appropriate box.
      1. Child abuse history
      2. Criminal history
      3. Failure to complete training
      4. Failure to follow agency policy
      5. Falsification/misrepresentation of info
      6. Unfavorable home study
      7. Other
        1. Record an explanation if this reason is used.
  4. Closure (agency initiated)

    If the agency initiates closure of the home, check the Closure box.

    1. Record the date of the closure and an explanation.
      1. Reasons for closure may include, but are not limited to, adoption finalization, falsification of information, lack of follow through, no longer meets regulatory requirements, etc.

Applicant Appeal Activity (disapproval or home closure)

The applicant may appeal the agency’s decision to disapprove or provisionally approve their home under 55 Pa. Code Chapter 3700 (relating to foster family care agency) Section 72 (relating to foster family approval appeals).

  1. If a foster family or kinship (formal kinship care) family files an appeal, check the Resource Parent Has Filed Appeal box.
  2. If the appeal is upheld, check the Appeal Upheld box and record the date.
    1. Record any restrictions to approval.
  3. If the appeal is denied, check the Appeal Denied box and record the date.
    1. Record the basis for the appeal.

Special Needs Family is Approved to Serve
(Check All That Apply)

Check the boxes for all the types of special needs a family is approved to serve. For clarification on the requirements in this section, please refer to Act 160, Section II.D.2.x for additional information.

  1. Boxes are included for:
    1. Abuse history
    2. Alcohol exposed
    3. Drug exposed infant
    4. Emotional disability
    5. HIV
    6. MH diagnosis (mental health)
    7. MR diagnosis (mental retardation)
    8. Multiple placement history
    9. Neglect history
    10. Physical disability
    11. Runaway history
    12. Sexual abuse history
    13. Siblings
      1. Record the number of siblings a family is approved to serve.
    14. Special education student
    15. Special medical care
    16. Other.
      1. Record other special needs.
  2. Record the maximum number of children approved to be placed in the home.

All Previous Foster Care/Adoption Agency Affiliations
(attach additional page, if needed)

All previous foster family care and/or adoption agency affiliations must be listed in this section. Additional pages may be used, if needed.

  1. Record the agency’s full name, address (including county), telephone number and contact person for each previous agency affiliation.
  2. Check the box for Not Applicable if no previous affiliations exist, and proceed to the next section.

Type of Child That May Be Placed in This Home

In this section, the registering agency details the family’s choice for the type of child they are willing to consider.

  1. Race/Ethnicity. Check All that Family Will Accept
    1. Check the block(s) of each race or ethnic group the family will accept. Choices are:
      1. American Indian/Alaska Native (race)
      2. Asian (race)
      3. Black/African American (race)
      4. Hispanic (ethnicity)

        5. Note: If this choice is selected, preferred races must also be indicated.

      5. More than one race (matches may include any races checked)

        6. Note: If this choice is selected, all the races a family will consider must also be checked.

      6. Native Hawaiian/other Pacific islander (race)
      7. White (race)
  2. Gender
    1. Family’s preference for Either, Female or Male gender.
  3. Number of children and age range
    1. Family’s preferred age range and indication if they will consider a single child and/or a sibling group.
    2. If the sibling group box is checked, indicate the maximum number of siblings they can serve.

Family Information

General information about the family is reported for:

  1. The occupation of the applicants, including a stay-at-home parent.
  2. Any special needs training or experience the applicants have.
  3. The type of neighborhood (rural, urban, suburban) in which the applicants live.

STOP here if family has child in pre-adopt placement or if family has been disapproved.

STOP Check the box in this section, and do not fill out the rest of the form, ONLY if the family has a child in pre-adopt placement or if the family was disapproved.

Characteristic of Children That Family Prefers

In this section the registering agency details the family’s choice for the type of child they would like to foster or adopt. This section may not apply to kinship (formal kinship care) care applicants applying on behalf of a specific child or children.

  1. General sections of Health, Education, Characteristics and Behaviors, Family Connectedness and History and the Adoptive Family’s Feelings Towards Openness each contain multiple statements where a family can indicate preference.
  2. For each statement listed, indicate a preference level of Preferred, Acceptable, Will Consider, or Unacceptable.
    1. Indicate the preference level with an X.
    2. If responses are different for foster care than for an adoption, indicate “F” for foster care and “A” for adoption, instead of “X.”
    3. Additional Comments may be provided at the end of this section.

Signature of Agency Worker is Required

Agency worker signs and dates the application, indicating completion and approval of the family.

  1. If the form is submitted electronically, submission will serve as the signature.
  2. If the form is submitted using a hard copy, signature and date is required.