FGP Application

All information is required to meet Federal and State guidelines.
✕
Your name*
Prefix First Middle Last
Home address*
Street Address Address Line 2 City State ZIP Code
Email*
Enter Email Confirm Email
Home phone*
Mobile phone
Do you text?*
- Yes
- No
Date of birth*
MM slash DD slash YYYY
Current age*
Shirt Size*
Have you resided in any state other than Texas?*
- Yes
- No
What other state(s) have you lived in?*
- Alabama
- Alaska
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- District of Columbia
- Florida
- Georgia
- Hawaii
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
- Armed Forces Americas
- Armed Forces Europe
- Armed Forces Pacific
What is your highest level of education completed?*
Marital status*
- Single
- Married
- Divorced
- Widowed
Veteran
- Yes
- No
What branch?*
Ethnicity/Race
- American Indian or Alaska Native
- Asian
- Black or African American
- Hispanic or Latino
- Native Hawaiian or Other Pacific Islander
- White
If there are any special accommodations needed to assist you in service, please list below:
Driver's License Number
Expiration Date
MM slash DD slash YYYY
Copy of Driver's License or State-issued ID
Max. file size: 128 MB.
If possible, please include a copy of your Driver's License or State-issued ID.
Number of Persons Living in Your Home (including yourself)*
Please enter a number greater than or equal to 1.
Relationships with others in household*
Please list the relationship of others to you in your household.
Have you ever been convicted of a felony?*
- Yes
- No
Please describe your conviction*
Do you use any illegal drugs according to Texas statutes?*
- Yes
- No
Physical Condition*
- Excellent
- Good
- Fair
- Poor

I prefer to serve:*
I prefer to serve children between the ages of:*
I plan to use the following methods of transportation:*
- Drive
- Public Transportation
- Be Driven
Why do you want to be a Foster Grandparent?*
Previous Occupation(s) and/or Volunteer Experience*
Special skills, certifications, hobbies, and/or interests*
How did you hear about the Foster Grandparent Program?*

Please provide three (3) character references. These must be individuals to whom you are not related.
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Reference #1*
First Last
Phone
Address for Reference #1*
Street Address Address Line 2 City State ZIP Code
Reference #2*
First Last
Phone
Address for Reference #2*
Street Address Address Line 2 City State ZIP Code
Reference #3*
First Last
Phone
Address for Reference #3*
Street Address Address Line 2 City State ZIP Code

Social Security (Monthly)*
Other Income (Monthly)*
Documentation will be required to verify eligibility.
Annual (out of pocket) medical expenses
(If needed to qualify)
Total Annual Income (less medical expense)*

Consent for Criminal History Check*
I give my permission
I hereby give my permission to the Texoma Senior Corps Program to obtain information relating to my criminal history record through the National Service Criminal History Check process which includes information obtained through up to three components:
- the National Sex Offender Public Website (NSOPW),
- the Texas Department of Public Safety, and
- a fingerprint-based FBI check through their specific databases or through CNCS-approved vendors such as Fieldprint and Truescreen agencies.
The criminal history record, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudications. I understand that this information will be used, in part, to determine my eligibility for an employment/vollunteer position with this Senior Corps authorized grantee organization. I understand that if I have been convicted of murder or required to register as a sex offender, I am ineligible to work or serve in this position. I also understand that as long as I remain an employee or volunteer here, the criminal history records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history and a procedure is available for clarification if I dispute the record as received.

I do, for myself, heirs, executors and administrators, hereby remise, release and forever discharge and agree to indemnify the Texoma Council of Governments and its entities, directors, employees and agents, harmless for any and against any and all causes of actions, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever and any and all related attorneys' fees, court costs and other expenses resulting from the investigation of my background in connection with my application to become a volunteer/staff member.
Terms & Agreement*
I understand
I understand that volunteering for the Foster Grandparent Program is a firm commitment to serving the minimum hours required. Program acceptance is contingent upon meeting all CNCS requirements. I certify that I am at least 55 years of age and, if applicable, I maintain automobile liability insurance equal to or greater than the minimum required by state law.

I certify that to the best of knowledge all information on this application is true and correct.
Name
This field is for validation purposes and should be left unchanged.

FGP Application FormFGP Application Form

FGP Volunteer Application