Early Literacy Referral - Foundation for Foster ChildrenFoundation for Foster Children

Submitter Information

Submitter Name*

First Last

Submitter Email*

Relation to the Child*

Caregiver
Case Manager/Caregiver Support
GAL

Child Information

FSFN ID

Child Name*

First Last

Date of Birth*

Gender*

Female
Male

Ethnicity*

Parental Rights Terminated?*

Yes
No
Pending
Unknown

Address where child resides:*

Street Address Address Line 2 City State ZIP Code

County of Residence*

Orange
Osceola
Seminole
Other

Placement Type*

Foster Home
Relative
Non-Relative

Has anyone in the most recent placement tested positive for COVID-19?*

Does the youth have a diagnosis: mental, physical, behavioral, educational, etc?*

Please attach CBHA

Max. file size: 50 MB.

Is the youth involved in FFC Tutoring or FFC funded classes/lessons?*

Educational History

Daycare/ School Currently Attending*

Daycare/School Type*

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.

Caregiver Information

Caregiver Name*

First Last

Caregiver Phone Number*

Caregiver Email*

Child Welfare Team Information

Who will be the primary contact for Early Literacy services?*

If other, please indicate role*

Is the case likely to close in the next two months?*

Primary Contact Name*

First Last

Primary Contact Phone Number*

Primary Contact Email*

Case Management Agency*

County Case Managed Out of:*

Orange
Seminole
Osceola

Case Manager Name

First Last

Case Manager Phone Number

Case 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 Services

Early 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 child's school readiness, and increase their child's chances of future academic success. The Early Literacy Coach will work with parents to track personalized milestones for each child’s literacy development and understand important developmental milestones. Additionally, parents and children will be provided with funded opportunities and coordinated activities to develop, enhance and learn.

I agree to weekly meetings and/or coordinated activities. In addition, to 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 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 name

Electronic Signature Consent to Services

By checking this box you accept this electronic signature.

Photo/Testimony Release

Foundation 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 consent
I do not give consent
I do not have permission to provide consent

Photo/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.

Early Learning Referral

Submitter Information

Child Information

Educational History

Caregiver Information

Child Welfare Team Information

Consent to Services

Photo/Testimony Release