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2024 Brief Referral

Welcome to Empower, personalized advocacy support services!

After completing this form, we will reach out to you to complete the full Referral Form

Any questions, please contact Empower Manager, Keely Popkin kpopkin@ffc.org

"*" indicates required fields

Step 1 of 6

16%

Youth Information

Youth Name*
MM slash DD slash YYYY
Gender*
Placement Type*

Address where you reside:*
County of Residence*

Youth's Needs

Needs - Please select all areas you hope to have your Advocate assist with:*

Primary Support

Primary Support Name*
Is the youth currently enrolled in one of the following programs?*

Release of Information

By signing below, I approve the release of the confidential information provided in this referral to FFC, its contracted tutoring agencies and its funding agencies, including but not limited to, Orange County Commission for Children and Embrace Families.
Please type first and last name
Electronic Signature: Release of Information

Consent to Services

The Foundation for Foster Children is committed to ensuring that every student in foster care achieves educational success. Our Educate Program aims to decrease the academic gap among foster children and to improve academic performance and advancement from one grade to the next. Consent must be provided by the caregiver, caregiver support, IL specialist, GAL, or their respective supervisors. Consent is effective until December 31st, 2024
Consent is being given by*

Consent to Advocacy Services

Advocacy services include: supportive services, life skills development and training, and financial support through Empower Success Funding. Advocates work with youth to strengthen independence and support their goals. This includes identifying individual needs and linking youth to internal programs and community resources. The Advocate provides advocacy, planning and coaching to ensure each youth receives personalized support to achieve success. Youth 18 and older must provide direct consent before services will be initiated. Consent must be provided by the caregiver, caregiver support, IL specialist, TSS, GAL or their respective supervisors before services will be initiated for youth 14-17.
Due to Covid-19, a number of FFC activities and events have been moved to virtual platforms. The youth's Advocate will assist with coordinating access.
Due to Covid-19, a number of FFC activities and events have been moved to virtual platforms. The youth's Advocate will assist with coordinating access.
Consent to Services Statement*
Consent to Services Statement*
Please type first and last name
Electronic Signature Consent to Services

Media/Photo Consent Form and Testimonies

This consent and release form grants permission to Foundation for Foster Children for the use of testimonies, photograph(s) or electronic media images. Images will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time archived. Media/Photo/Testimonies consent forms and release will expire may 1st of 2024, unless:

*Child turns 18, new consent form will be required

*Change in placement for children under 18, new consent form will be required with current legal guardian signature.

*Legal guardian/child/young adult choices to withdraw their consent for any reasons.

Photo and Testimony Consent*
Media/Photo Consent Form and Testimonies*
Electronic Signature: Photo/Testimony Release

Rights and Responsibilities

Rights*
Responsibilities*
Consent*

Waiver and Release of Liability Form

In return for being allowed to participate in the Foundation for Foster Children volunteer activities and all related activities, including any activities incidental to such participation (“Volunteer Activities”), the undersigned Volunteer or Parent/Legal Guardian of Volunteer if Volunteer is under age 18 (hereafter referred to using “I”, “me”, or “my”) releases and agrees not to sue the Foundation for Foster Children or its officers, directors, employees, sub-contractors, sponsors, agents and affiliates (“the Foundation”) from all present and future claims that may be made by me, my family, estate, heirs, or assigns for property damage, personal injury, or wrongful death arising as a result of my participation in the Volunteer Activities wherever, whenever, or however the same may occur.

I understand and agree that the Foundation is not responsible for any injury or property damage arising out of the Volunteer Activities, even if caused by their ordinary negligence or otherwise.

I understand that participation in the Volunteer Activities involves certain risks, including, but not limited to, serious injury and death. I am voluntarily participating in the Volunteer Activities with knowledge of the danger involved and I agree to accept all risks of participation. I also agree to indemnify and hold harmless the Foundation for all claims arising out of my participation in the Volunteer Activities.

I understand that this document is intended to be as broad and inclusive as permitted by the laws of the state in which the Volunteer Activities take place and agree that if any portion of this Agreement is invalid, the remainder will continue in full legal force and effect. I also acknowledge that the Foundation have not arranged and do not carry any insurance of any kind for my benefit or that of Volunteer (if Volunteer is under 18), my parents, guardians, trustees, heirs, executors, administrators, successors and assigns. I represent that, to my knowledge, I am in good health and suffer no physical impairment that would or should prevent my participation in Volunteer Activities.

I also understand that this document is a contract which grants certain rights to and eliminates the liability of the Foundation.

Is the student over or under 18 years old?*
Student Over 18*
Parent/Legal Guardian Providing Consent*
Parent/Legal Guardian if student is Under 18*
  • 2024 Brief Referral

Phone: 407.422.4615 | Fax:
2265 Lee Rd Suite 203, Winter Park, FL 32789
Email: info@foundationforfosterchildren.org

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