Early Literacy Referral Early Literacy services are open to children birth- Kindergarten, living in Orange County. Referrals may only be completed by youth, caregiver or a member of the child’s child welfare team: case manager, caregiver support, GAL & respective supervisors. Participation in services is not mandatory and active participation is expected. Submitter InformationSubmitter Name* First Last Submitter Email* Relation to the Child*CaregiverCase Manager/Caregiver SupportGALChild InformationFSFN IDChild Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Gender*FemaleMaleEthnicity*African-AmericanAsian-AmericanCaucasianHispanic-LatinoMulti-EthnicOtherParental Rights Terminated?*YesNoPendingUnknownAddress where child resides:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County of Residence*OrangeOsceolaSeminoleOtherPlacement Type*Foster HomeRelativeNon-RelativeHas anyone in the most recent placement tested positive for COVID-19?*YesNoUnknownDoes the youth have a diagnosis: mental, physical, behavioral, educational, etc?*YesNoPendingUnknownPlease attach CBHAIn FFC Tutoring or FFC funded classes/lessons?*YesNoUnknownEducational HistoryDaycare/ School Currently Attending*Daycare/School Type*Traditional DaycareHeadstartVPKKindergartenN/AIs this student in Exceptional Student Education (ESE)?*YesNoUnknownIs this student in English Speakers of Other Languages (ESOL)?*YesNoUnknownDoes this student have an IEP?*YesNoUnknownPlease attach IEPPlease attach most recent gradesCaregiver InformationCaregiver Name* First Last Caregiver Phone Number*Caregiver Email* Child Welfare Team InformationWho will be the primary contact for Early Literacy services?*Case ManagerCaregiver SupportGALOtherIf other, please indicate role*Is the case likely to close in the next two months?*Most likely noMost likely yesNot SureCase is closedPrimary Contact Name* First Last Primary Contact Phone Number*Primary Contact Email* Case Management Agency*CHSGCJFSOHUCHNCounty Case Managed Out of:*OrangeSeminoleOsceolaCase Manager Name First Last Case Manager Phone NumberCase Manager Email Please include the name, phone number and email of any other child welfare team members to be included in collaboration & communication.Consent to ServicesEarly Literacy services include modeling and observing activities for parent led and engaged early language, literacy and early reading development. Services will help parents learn how to interact with their children to develop literacy skills, improve their children's school readiness, and increase their children's chances of future academic success. The Early Literacy Coaches will work with parents to track personalized milestones for each child’s literacy development, understand important developmental milestones. Additionally, parents and children will be provided with funded opportunities and coordinated activities to develop, enhance and learning.I agree to weekly meetings and or coordinated activities. In addition, to actively participate in all aspects of program delivery.*YesDue to Covid-19, a number of FFC activities and events have been moved to virtual platforms. The child's Early Literacy Coach will assist with coordinating access.Consent to Services Statement*By signing below, I hereby give the Foundation for Foster Children (FFC) consent to provide Early Literacy services to the child named herein. I understand this includes Early Literacy Coach meetings with child, caregiver and professionals such as daycare providers, school personnel and community support groups. I agree to share notes and records, in addition to provide consent to Early Literacy Coach to share information, as necessary, to maximize collaboration and communication; and will inform the Coach of any upcoming meetings regarding the child’s needs, including court hearings; parent-teacher conferences, etc.Electronic Signature: Consent to Services*Please type first and last nameElectronic Signature Consent to Services By checking this box you accept this electronic signature. Photo/Testimony ReleaseFoundation for Foster Children Photo/Testimony Release: provides the Foundation for Foster Children (FFC) with permission to use photographs or testimonies provided in internal and external communications such as program newsletters and FFC marketing materials including, but not limited to, the website and print materials of FFC. Youth 18 and older must provide direct consent.Photo/Testimony Release: Consent*I do give consentI do not give consentI do not have permission to provide consentPhoto/Testimony Release Statement* By signing below, I hereby give the Foundation for Foster Children (FFC) permission to use photographs or testimonies of the youth named herein. I understand that FFC may use photographs and testimonies in internal and external communications including program newsletters and FFC marketing materials including, but not limited to, the website and print materials. I understand that compensation in any form for the use of this likeness is prohibited. Photo/Testimony Release Statement* By signing below, I hereby do not give the Foundation for Foster Children (FFC) permission to use photographs or testimonies of the youth named herein. Photo/Testimony Release Statement* By signing below, I hereby am unable to give/deny the Foundation for Foster Children (FFC) permission to use photographs or testimonies of the youth named herein. Please provide the name, phone and email address of the individual with permission to provide/deny photo consent.Electronic Signature: Photo/Testimony Release*Electronic Signature: Photo/Testimony Release By checking this box you accept this electronic signature.