CT Foster Care IPPI Permanency Services - Creating Connections for Life Preliminary Questionnaire Date* Date Format: MM slash DD slash YYYY Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Who else lives with you:NameRelationshipNameRelationshipNameRelationshipHow to contact you:Home Phone*Cell PhoneWork PhoneWhen is the best time to reach you? : HH MM AM PM At what phone number?HomeCellWorkEmail* How did you hear about the program:*Preliminary Checklist:1. Are you at least 21 years of age?*YesNo2. Do you have a high school diploma or GED?*YesNo3. Do you have an extra bedroom? (Our kids need their own rooms)*YesNo4. Do you have a valid CT driver's license?*YesNo5. Do you have a reliable car with insurance?*YesNo6. Do you have sufficient income to support your household?*YesNo7. Have you or any household member been investigated by DCF?*YesNo8. Do you or any household member have arrest history?*YesNoIf you answered Yes to #7 or #8, please use the area below to explain:Security Code (please enter all letters and numbers)IF YOU HAVE QUESTIONS OR WANT TO TALK WITH A RECRUITER PLEASE CALL 203-317-2700 x134. Click Submit and we will be in touch within the next business day!