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

Child Name*

First Last

Date of Birth*

Gender*

Female
Male

Ethnicity*

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*

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.

Have you completed the FFC Rights and Responsibilities Acknowledgement?

Yes
No
I'm not sure

Early Learning Referral

Submitter Information

Child Information

Educational History

Caregiver Information

Child Welfare Team Information

Consent to Services

Media/Photo Consent Form and Testimonies