Short-Term Foster Care Placement Agreement Form
Child Information
Name
Date of Birth
Gender
Allergies / Medical Conditions
Foster Parent / Caregiver Information
Name(s)
Address
Phone
Email
Placement Details
Start Date
End Date
Reason for Placement
Contact Person / Caseworker
Name
Agency / Organization
Phone
Email
Agreements
I agree to provide a safe, nurturing environment for the child.
I agree to follow the terms set by the caseworker/agency.
I understand this placement is short-term and may end at any time.
Foster Parent / Caregiver Signature
Date
Caseworker Signature
Date