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2. Foster / Adoptive Parent Inquiry Disclaimer
   Thank you for your interest in becoming a foster or adoptive parent for Pitt County Department of Social Services. If you are not currently licensed as a foster parent and are interested in obtaining additional information about our foster/adoptive parent program, please complete this inquiry form. After completing the inquiry form, you will receive a phone call from one of our foster/ adoptive parent recruiters within ten business days. If you have any questions, you may also contact 252-902-1244 or email Chandra.Mewborn@pittcountync.gov.
4. Name
5. Email Address
7. Address
8. Apartment / Suite #
10. City
11. State
12. Zip Code
14. Phone Number
15. Fax Number
17. Gender

    1. Male
    2. Female
18. Date of Birth
    (mm/dd/yyyy)
19. Marital Status

    1. Married
    2. Single
    3. Divorced
    4. Widowed
    5. Domestic Partner
    6. Other
21. Other Family Members (18 years of age or older)
23. Name
24. Gender

    1. Male
    2. Female
25. Date of Birth
    (mm/dd/yyyy)
27. Name
28. Gender

    1. Male
    2. Female
29. Date of Birth
    (mm/dd/yyyy)
31. Name
32. Gender

    1. Male
    2. Female
33. Date of Birth
    (mm/dd/yyyy)
35. Name
36. Gender

    1. Male
    2. Female
37. Date of Birth
    (mm/dd/yyyy)
39. Name
40. Gender

    1. Male
    2. Female
41. Date of Birth
    (mm/dd/yyyy)
43. Interested In

    1. Foster
    2. Adoption
45. Comments
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field