MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION APPLICATION TO PROVIDE RESPITE CARE
Name	Date of Birth	SSN
Spouse	Date of Birth	SSN
Home address:
Telephone number:
Email address:
Please list other persons residing in the home, date of birth, relationship to head of household, and Social Security Number. Attach additional pages, if necessary.
Name	Date of Birth	Relationship to Head of Household	SSN
Please respond to the following questions:
1. What is your understanding of the Children’s Division Respite Care program?
2. What motivated you to become a Children’s Division Respite Care provider?
3. What child care experience do you have?
4. Are you currently providing care for other unrelated children? If yes, how many unrelated children are you providing care for in your home/facility?
5. What is your understanding of Children’s Division regulations regarding corporal punishment?
6. What is your understanding of the laws governing confidentiality of foster children placed in your home?
I (We), the undersigned, certify that I (we) have received an explanation of the Respite Care program as provided through the Children's Division and understand the terms as stated in this application.
Signature	Date	Signature	Date
This is to certify that I have completed the walk through of the applicant’s home and completed the Respite Care Provider Checklist, CS-RC-2.
Children's Service Worker Signature	Date
This is to certify that I have provided an explanation of the Respite Care Program as provided through the Children's Division to the Respite Care applicant.
Children's Service Worker Signature	Date