Advocacy Referral

Welcome to Empower, personalized advocacy support services!

Currently, we’re at full capacity, however; we encourage you to complete a referral as a spot can become available at any time.

While we monitor Advocacy availability, please join us for some exclusive offers! During this period, you’ll have access to Advocacy:

-Events

-Life skills workshops

-Life skill Library

-And other opportunities as they become available.

Thank you for your patience and understanding,

Any questions, please contact Empower Manager, Carmen Garcia at cgarcia@ffc.org

"*" indicates required fields

Submitter Information

Date*

Submitter Name*

First Last

Submitter Email*

Relation to the Youth*

Self (Youth over 18)

Caregiver

IL Specialist/TSS

Case Manager/Caregiver Support

GAL

Youth Information

Youth Name*

First Last

Youth Email*

Youth Phone Number*

Date of Birth*

Age*

Is the youth a parent?*

Gender*

Female

Male

Ethnicity*

African-American

Asian-American

Caucasian

Hispanic-Latino

Multi-Ethnic

Other

Placement Type*

Foster Home

Relative

Non-Relative

Group Home

In-Home Court Ordered/Voluntary/Diversion

Age 18+

Other

Group Home Name*

Housing Type*

Renting

Student Housing

Living with a friend/family member

Transitional housing

Other

Does the youth have a diagnosis: mental, physical, behavioral, educational, etc? If so, please provide the student's diagnosis?*

Address where youth resides:*

Street Address Address Line 2 City State ZIP Code

County of Residence*

Orange

Osceola

Seminole

Grade*

School Currently Attending*

Is the youth's case open?*

Is the youth employed or in secondary education? (for students 18+)*

Is the youth incarcerated?*

Is the youth on track to graduate HS? (if student is in HS)*

Is the youth pregnant?*

Is the youth homeless?*

Risks - Please select all past/present risk factors:*

If other, please specify*

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

Housing

Transportation

Employment

Education

Mental/Physical Health

Parenting

Financial Literacy

Life skills development

Other

If other, please specify

Child Welfare Team

Is the youth's case managed by a state/case management agency or community organization?*

Child Welfare Agency/Case Management

Community Organization

Case Manager

Case Management Agency*

CHS

GCJFS

OHU

Other

Case Manager Name*

First Last

Child Welfare Team: Primary Contact Phone Number*

Child Welfare Team: Primary Contact Email*

County Case Managed Out of:*

Orange

Seminole

Osceola

Other

Please include the name, phone number and email of any other child welfare team members to be included in collaboration & communication.

Please attach CBHA

Max. file size: 50 MB.

Community Organization

Please specify the community organization's name*

Contact Name*

First Last

Contact Phone Number*

Contact Email*

Primary Support - Caregiver Information

Primary Support Name*

First Last

Primary Support Number*

Primary Support Email*

Educational History

Is the youth actively participating in school?*

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

EFC

PESS

Opted out of care

N/A

School Type*

Has the youth taken the GED or any portion of it?*

Is this student in Exceptional Student Education (ESE)?*

Is this student in English Speakers of Other Languages (ESOL)?*

Does this student have an IEP?*

Please attach IEP

Max. file size: 50 MB.

Please attach most recent grades

Max. file size: 50 MB.

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.

Electronic Signature: Release of Information*

Please type first and last name

Electronic Signature: Release of Information

By checking this box you accept this electronic signature.

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*

Self (Student over 18)

Caregiver/GAL

Case Manager

N/A - I do not have permission to provide consent

Student UNDER 18

Please provide the name, phone and email address of the individual with permission to provide/deny photo consent. Services won't start until we have received consent to services*

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.

I agree to meet with Advocate weekly, prepared to participate in meetings and coordinated activities. In addition, I agree to attend workshops & actively participate in all aspects of program delivery.*

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.

I agree the youth will meet with Advocate weekly, prepared to participate in meetings and coordinated activities. In addition, the youth will attend workshops & participate in all aspects of program delivery.*

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*

By signing below, I hereby give the Foundation for Foster Children (FFC) consent to provide Advocacy services to the youth named herein. I understand this includes Advocate meetings with youth and professionals such as caregivers, school personnel and employers. I agree to share notes and records, in addition to provide consent to Advocate to share information, as necessary, to maximize collaboration and communication; and will inform the Advocate of any upcoming meetings regarding the youth’s needs, including Youth Transition meetings, IEP meetings; parent-teacher conferences, etc.

Consent to Services Statement*

By signing below, I hereby give the Foundation for Foster Children (FFC) consent to provide me (youth named herein) with Advocacy services. I understand this includes Advocate meetings with myself and my support team including professional such as child welfare team and school personnel. I agree share records and that the Advocate may share information, as necessary, to maximize service delivery; and I will inform my Advocate of any upcoming meetings regarding my needs, including Youth Transition meetings, IEP meetings, etc.

Electronic Signature: Consent to Services*

Please type first and last name

Electronic Signature Consent to Services

By checking this box you accept this electronic signature.

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*

I do give consent

I do not have permission to provide consent

Please provide the name, phone and email address of the individual with permission to provide/deny photo consent.*

Media/Photo Consent Form and Testimonies*

By signing below, I hereby give the Foundation for Foster Children (FFC) permission to use my photograph and use an approved story in FFC marketing materials including, but not limited to, the website and print materials of FFC. I understand that I will not receive compensation for the use of this likeness in any form.

Electronic Signature: Photo/Testimony Release*

Electronic Signature: Photo/Testimony Release

By checking this box you accept this electronic signature.

Rights and Responsibilities

Rights*

1. Freedom from discrimination: You have the right to freedom from discrimination related to age, ethnicity, national origin, gender, disability, religion, sexual orientation, gender orientation, values and beliefs, marital status, etc.

2. Identity and provider credentials: You have the right to know the identities, titles, specialties and affiliations of all staff and volunteers of FFC and its contracted tutoring providers, as well as anyone else involved in your service.

3. Rules, regulations and policies and procedures: You have the right to know about FFC’s rules, regulations and policies and procedures that are pertinent to the mission or type of service which you receive.

4. Service plan: You have the right to be aware of the decisions about your service. You have the right to select when you would like to receive services and to decide when to stop services. You have the right to change your service plan at any time. You have the right to refuse to participate in any service. You may change your mind and return to services after refusing service without affecting ongoing or other FFC services you may be involved in.

5. Confidentiality: You have the right to confidentiality of all information given to or obtained per rules and regulations of the US Department of Health and Human Services, Health Resources and Services Administration, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), US Department of Justice Civil Rights Division, JTFPI, and other local, county, state and federal laws, directives, and/or guidelines.

6. Client grievance procedures: You have the right to voice complaints at any time. You have the right to receive a response and resolution to any grievance, complaint or suggestion in writing in a timely manner according to FFC’s Client Grievance Policies and Procedures.

Responsibilities*

1. Correct and complete information: You have the responsibility to provide correct and complete information to FFC about your youth’s demographics, case status, academic records, and all other information required during the client intake process. You have the responsibility to provide immediate notification of any changes to placement or case status.

2. Service plan adherence: You have the responsibility of following the agreed upon service plan. And must give adequate notice if there will be a change to the plan.

3. Voicing complaints, problems, and/or suggestions: You have the responsibility for voicing complaints, problems, and/or issues in an appropriate and timely manner via FFC’s grievance process.

Consent*

I understand and accept the terms of FFC's Rights and Responsibilities agreement

Signature*

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?*

Under 18

Over 18

Student Over 18*

I have read this form and understand that by signing this form, I am giving up legal rights and remedies. I agree to the privacy policy. I am of legal age and am freely signing this agreement.

Parent/Legal Guardian Providing Consent*

First Last

Parent/Legal Guardian if student is Under 18*

I am the parent or legal guardian of the Volunteer. I am of legal age and am freely signing this agreement. I have read this form and understand that by signing this form, I am giving up legal rights and remedies.

Electronic Signature - Waiver and Release of Liability*