2023 Birthday Celebration - Cake Request - Foundation for Foster ChildrenFoundation for Foster Children

Application Date*

Submitter Name*

First Last

Submitter Phone Number*

Submitter Email*

Relation to Child*

If other, please specify.*

Child's Information

Child's Name*

First Last

Child's Phone Number*

If under 18 you can provide caregiver,primary contact, mentor, etc phone number

Child's Email*

If under 18 you can provide caregiver, primary contact, mentor, etc email address

Date of Birth*

Age*

Does the youth have children?*

Yes

Gender*

Female

Male

Ethnicity*

African-American

Asian-American

Caucasian

Hispanic-Latino

Multi-Ethnic

Placement*

Foster Home

Group Home

Relative (Not Bio Parent)

Non-Relative Parent

Other

Group Home Name*

Address where child resides:*

Street Address Address Line 2 City State ZIP Code

Residing County*

Orange

Seminole

Osceola

Other

Grade*

School Currently Attending*

Is the youth case closed?*

Yes

N/A

Child Welfare Team

Is the youth case managed by an state agency/case manager or by a community organization?

Child Welfare Agency/Case Manager

Community Organization

Case Manager information

Case Management Agency*

Case Manager Name*

First Last

Case Manager Phone*

Case Manager Email*

Case Management County*

Community Organization

Please specify the community organization name*

Contact Name*

First Last

Phone*

Email*

Primary Contact Information

Caregiver, mentor, family member, etc.

Primary Contact Name*

First Last

Primary Contact Phone*

Primary Contact Email*

Celebration Club

The Foundation for Foster Children has partnered with our friends at Four Rivers to provide beautiful birthday cakes to celebrate our foster youth on their birthday. We ask for at least one week notice.

What birthday is the child/youth celebrating?*

Does the child have any food allergies?*

Unfortunately, at this time we are unable to accommodate food allergies through our Celebration Club partnership with 4 Rivers. If you would still like assistance with your youth's birthday cake, we can offer a $25 Visa gift card to assist with purchasing a food allergy friendly cake.*

Yes, i would like to pick up a gift card for my youth's cake on the pickup date below

Type of Cake*

Vanilla

Chocolate

Red Velvet

Cookie N' Cream

Type of Icing*

Vanilla

Chocolate

Preferred Pick-Up Date*

Please provide the name that you would like to be on the cake for the youth.

Number of people celebrating*

Please provide an idea of how the child would like the cake decorated with a theme or favorite character, and we will try our best to accommodate.*

Do you have an example or picture of what you would like this cake to look like? Awesome! Please attach here

Max. file size: 50 MB.

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 am willing to share my story and/or feedback and I give consent to use my photo.

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.

Consent for Release of Information*

I approve the release of the confidential information provided in this referral to FFC and its funding agencies, including but not limited to, Orange County Commission for Children.

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

2023 FFC Birthday Celebration Request

Child's Information

Child Welfare Team

Case Manager information

Community Organization

Primary Contact Information

Celebration Club

Media/Photo Consent Form and Testimonies

Rights and Responsibilities