Educational Tools and Resources -Foundation for Foster Children

Application Date*

Submitter Name*

First Last

Submitter Phone Number*

Submitter Email*

Relation to the youth*

If other, please specify.*

Youth Information

Youth Name*

First Last

Youth Phone Number*

Youth Email*

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 youth resides:*

Street Address Address Line 2 City State ZIP Code

Residing County*

Orange

Osceola

Seminole

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

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*

Educational Tools and Resources

Funding Categories*

If other, please describe*

Thank you for submitting a funding request for a laptop. As a friendly reminder, FFC provides ONE laptop per student. Students are eligible for a new laptop after 3 years. FFC provides an standard HP laptop for all students. Each laptop comes with its charger, and a case.

Cost of Activity/Item*

Is the youth registered for this activity?*

Yes

N/A

Activity Provider Name*

Activity Provider Phone*

Activity Provider Email*

Activity Provider Website

Activity Provider Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Please share any important information needed to process this request. For example, URL link for purchase, account information such as username and password, contact person related to this request, etc.

Release of Information

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

Electronic Signature: Release of Information*

Please type first and last name

Electronic Signature: Release of Information

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 before services will be initiated. Consent must be provided by the caregiver, caregiver support, IL specialist, TSS, GAL or their respective supervisors before services will be initiated for youth 14-17.

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.

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.

Signature*