2023-2024 Tutoring Request Form

The Foundation for Foster Children is currently accepting requests for professional tutoring services for Grades 6th - 12th, GED and College. Students must meet the criteria for approval. Please note that funding is limited and requests will be approved on a first come-first served basis for students with the most critical academic need. Additionally, continued service eligibility will be reviewed and determined quarterly.

Please keep in mind that professional Tutoring services will start in January 2024. FFC will serve up to 30 students from January 2024 to December 2024. Tutoring services will be paused June 2024 - August 2024. All 30 students will be approved for 4 hours of professional tutoring per month

Criteria for Approval

- Student is between 6th and 12th grade, getting GED or going to College

- Student must be living in or case-managed out of Seminole, Orange and or Osceola counties

-Student has to have an open dependency case

- Student is below grade level or has a GPA below 2.0

- Student does not have excessive absences from school

- Student was retained in the previous school year

- Student is a high-school senior for the 2023/2024 school year/working to obtain a GED

- Special circumstance that requires students to participate in professional tutoring services

Please allow 5-7 business days to process the request. An FFC or Embrace Families staff member will be in touch.

"*" indicates required fields

FFC Services

Have FFC funded profesional tutoring services before?

What Tutoring Agency did student work with?

Please check "Select All" to confirm that you understand FFC's criteria.

Submitter Information

Application Date*

Submitter Name*

First Last

Submitter Email*

Relation to Student*

Student Information

Student Name*

First Last

Student Phone Number*

Student Email*

Date of Birth*

Age*

Does the student have children?*

Yes

Gender*

Female

Male

Ethnicity*

African-American

Asian

Caucasian

Hispanic-Latino

Multi-Ethnic

Placement*

Foster Home

Group Home

Relative (Not Bio Parent)

Non-Relative Parent

Other

Group Home Name*

Address where student resides:*

Street Address Address Line 2 City State ZIP Code

Residing County*

Orange

Osceola

Seminole

Other

Grade*

School Currently Attending*

Is the youth currently enrolled in Florida Virtual School?*

Yes

Is the youth case closed?*

Yes

N/A

Is the youth currently enrolled in one of the following programs?*

EFC

PESS

Opted out of care

Other

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 Number*

Case Manager Email*

County Case Managed Out of:*

Orange

Seminole

Osceola

Other

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

Case Manager Supervisor Name

First Last

Supervisor Phone Number

Supervisor Email

Community Organization

Please specify the community organization name*

Community Organization - Contact Name*

First Last

Community Organization - Contact Phone*

Community Organization - Contact Email*

Primary Contact Information

Caregiver, mentor, family member, etc

Primary Contact Name*

First Last

Primary Contact Phone*

Primary Contact Email*

Is primary contact aware tutoring services are being requested?*

Yes

Tutoring Services

Type of tutoring student is interested*

Tutoring will most likely be taking place:*

Tutoring Availability

Monday

Tuesday

Wednesday

Thursday

Friday

Weekend

Educational History

Has the youth taken the GED or any portion of it?*

Does this student have a mental health diagnosis?*

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 indicate the current educational needs of this student:*

Math

Reading

Science

History

Other

Please indicate the "other" current educational needs of this student:

If you have a specific tutor request, like your student would like to work with a female or male tutor, someone who speaks another language, etc. Please provide those details here and explain how that will benefit the student.

Please attach most recent grades (Report Card Only)*

Max. file size: 50 MB.

Consent to Services

The Foundation for Foster Children is committed to ensuring that every student in foster care achieves educational success. Our Educate Program aims to decrease the academic gap among foster children and to improve academic performance and advancement from one grade to the next. Consent must be provided by the caregiver, caregiver support, IL specialist, GAL, or their respective supervisors. Consent is effective until December 31st, 2024

Consent is being given by*

Self (Student over 18)

Caregiver/GAL

Case Manager

N/A - I do not have permission to provide consent

Please provide name, email, and phone number of the person who can provide consent. Services won't start until we have received consent to services.*

Consent to Services Statement*

By signing below, I hereby give the Foundation for Foster Children (FFC) consent to provide the youth named herin with tutoring services. I understand this includes meeting with a tutor on a consistent basis in an environment conducive to learning.

Consent to Release of Information*

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.

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 and Testimony Consent*

I am willing to share my story and/or feedback and I give consent to use my photo.

I don't want to share my story and/or feedback.

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*

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.

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.

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*