Early Literacy Referral - Foundation for Foster ChildrenFoundation for Foster Children

Early Learning Referral

Early Literacy Coaches works with the youth and their caregiver in early language and reading development. Early Literacy services are open to children birth- Kindergarten, residing in Orange County. Referrals may only be completed by the caregiver or a member of the child’s child welfare team: case manager, caregiver support, GAL & respective supervisors. Participation in services is not mandatory but active participation is expected.

Submitter Information
Submitter Name*
First Last
Submitter Email*
Relation to the Child*
- Caregiver
- Case Manager/Caregiver Support
- GAL
Child Information
Child Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
- Female
- Male
Ethnicity*
- African-American
- Asian-American
- Caucasian
- Hispanic-Latino
- Multi-Ethnic
- Other
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
Does the youth have a diagnosis: mental, physical, behavioral, educational, etc?*
Please attach CBHA
Max. file size: 50 MB.
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*
- CHS
- GCJFS
- OHU
- CHN
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.
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/Testimony Release: 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*
- Select All
- 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*
- Select All
- 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

Early Learning Referral

Submitter Information

Child Information

Educational History

Caregiver Information

Child Welfare Team Information

Consent to Services

Media/Photo Consent Form and Testimonies

Rights and Responsibilities

Waiver and Release of Liability Form