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Applicant Name

Cell Phone Number

Home Phone Number

Work Phone Number

Email Address

Mailing Address

City

County

Zip Code

Type of Application

Best Time to be Reached

Children Preferred

Number of Children

Age Range

Gender

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Please do not use this form to report abuse and neglect. The abuse/neglect number for your county is located on the SCDSS webpage at www.dss.sc.gov. For emergencies, please contact your local law enforcement office.

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Do you have a complaint regarding services being provided to a child by a state agency? Please submit your complaint by phone (1-800-206-1957) or an electronic submission form here with the South Carolina Department of Children's Advocacy.