Natural father’s name ________________________________________________________________ Alive/dead/unknown Natural mother’s name _______________________________________________________________ Alive/dead/unknown Natural father or guardian’s address Natural mother or guardian’s address LC 1 Village Parish Subcounty County Details of foster child’s brothers, sisters and relatives Names Addresses Alive/dead Where was the child living immediately prior to this foster placement? (Please give names and addresses of carers or institution). ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Case history of the child and his/her family _________________________________________________________________________________________________ _________________________________________________________________________________________________