PCC/PCP Foster Parent & Respite Care Training Memorandum of Understanding Date(Required) MM slash DD slash YYYY Name of Individual Completing MOU(Required) First Last Name of PCC/PCP AgencyAddress PCC/PCP(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Counties Your Agency Serve in Kentucky(Required)StatewideAdair CountyAllen CountyAnderson CountyBallard CountyBarren CountyBath CountyBell CountyBoone CountyBourbon CountyBoyd CountyBoyle CountyBracken CountyBreathitt CountyBreckinridge CountyBullitt CountyButler CountyCaldwell CountyCalloway CountyCampbell CountyCarlisle CountyCarroll CountyCarter CountyCasey CountyChristian CountyClark CountyClay CountyClinton CountyCrittenden CountyCumberland CountyDaviess CountyEdmonson CountyElliott CountyEstill CountyFayette CountyFleming CountyFloyd CountyFranklin CountyFulton CountyGallatin CountyGarrard CountyGrant CountyGraves CountyGrayson CountyGreen CountyGreenup CountyHancock CountyHardin CountyHarlan CountyHarrison CountyHart CountyHenderson CountyHenry CountyHickman CountyHopkins CountyJackson CountyJefferson CountyJessamine CountyJohnson CountyKenton CountyKnott CountyKnox CountyLaRue CountyLaurel CountyLawrence CountyLee CountyLeslie CountyLetcher CountyLewis CountyLincoln CountyLivingston CountyLogan CountyLyon CountyMadison CountyMagoffin CountyMarion CountyMarshall CountyMartin CountyMason CountyMcCracken CountyMcCreary CountyMcLean CountyMeade CountyMenifee CountyMercer CountyMetcalfe CountyMonroe CountyMontgomery CountyMorgan CountyMuhlenberg CountyNelson CountyNicholas CountyOhio CountyOldham CountyOwen CountyOwsley CountyPendleton CountyPerry CountyPike CountyPowell CountyPulaski CountyRobertson CountyRockcastle CountyRowan CountyRussell CountyScott CountyShelby CountySimpson CountySpencer CountyTaylor CountyTodd CountyTrigg CountyTrimble CountyUnion CountyWarren CountyWashington CountyWayne CountyWebster CountyWhitley CountyWolfe CountyWoodford CountyName of Individual to Receive New Foster Family Information from OCA Trainings(Required) First Last Email of Individual to Receive New Foster Family Information(Required) Phone Number of Individual to Receive New Foster Family Information(Required)Memorandum of Understanding Between Orphan Care Alliance & PCC/PCP Agency Printed and Signed on FormConsent(Required) I have read and agree with the Life Coach Mentor Program Authorization to ParticipateWHEREAS, Orphan Care Alliance, Inc. (OCA) is a non-profit entity dedicated to assisting and supporting families and children; and WHEREAS, Printed & Signed PCC/PCP Agency on This Form, a Private Childcare Provider, licensed in the state of Kentucky, is responsible for the recruitment and training of foster parents and respite caregivers to provide placement of children in the foster care system. WHEREAS, the Department for Community Based Services, (DCBS), has entered into a Memorandum of Understanding with OCA to provide recruitment and training of foster families and respite caregivers. WHEREAS, OCA is willing, ready, and able to provide assistance to Printed & Signed PCC/PCP Agency on This Form in the recruitment and training of foster families and respite caregivers. Now therefore, the parties agree as follows: • THE PRINTED & SIGNED PCC/PCP AGENCY ON THIS FORM accepts the OCA training called NTDC with approved modifications that align with our mission and faith-based values (state foster care training) as the foundation of 18 hours of in class training and 3 hours of online training toward becoming a therapeutic foster home. • THE PRINTED & SIGNED PCC/PCP AGENCY ON THIS FORM agrees that the OCA informed consent and release of information and records form will have Orphan Care Alliance, and THE PRINTED & SIGNED PCC/PCP AGENCY ON THIS FORM listed which allows for free exchange of information between, THE PRINTED & SIGNED PCC/PCP AGENCY, and Orphan Care Alliance. • THE PRINTED & SIGNED PCC/PCP AGENCY ON THIS FORM will inform OCA regarding the additional number of hours of training a family will need with their organization to become a therapeutic foster home. • THE PRINTED & SIGNED PCC/PCP AGENCY ON THIS FORM may provide information about their agency to OCA for distribution to those interested in therapeutic foster care or other services their agency provides. • THE PRINTED & SIGNED PCC/PCP AGENCY ON THIS FORM will supply OCA with their counties of operation so that OCA may provide accurate information to our foster parents being trained across Kentucky. • THE PRINTED & SIGNED PCC/PCP AGENCY ON THIS FORM will provide a primary point of contact to which OCA will share their information to families and also transfer their training information and paperwork. • OCA will not allow THE PRINTED & SIGNED PCC/PCP AGENCY ON THIS FORM to speak at OCA foster care trainings; however, we will share THE PRINTED & SIGNED PCC/PCP AGENCY ON THIS FORM information with our families as part of this agreement. • OCA will follow up with THE PRINTED & SIGNED PCC/PCP AGENCY ON THIS FORM and the foster family regarding a foster family’s progress in becoming active foster parents and placement status. This agreement is considered executed when fully signed by both THE PRINTED & SIGNED PCC/PCP AGENCY ON THIS FORM and OCA along with OCA’s receipt of which provides information requested above. Electronic Signature(Required) First Last TitleName of PCC/PCP AgencyDate(Required) MM slash DD slash YYYY CAPTCHA
