Enrichment Form 2018 Any foster child under the age of 23 in out-of-home care (foster care, relative care, non-relative care, and group homes) or in EFC/PESS residing in or managed from Orange, Osceola, or Seminole County is eligible to receive funds. Funds may be used for athletics, educational and social opportunities. Acceptable requests include participation on a sports team, taking dance or music classes, enrollment in a martial arts program, attending school field trips or dances, purchase of senior class photos, driving lessons, purchasing textbooks, and apartment assistance for transitioning youth. At this time, we are only able to fund one ongoing activity per child. This does not include requests for field trips, sports equipment or other items/activities that only occur one time. For requests for summer camp and tutoring, please do not use this form. As a policy, we do not reimburse. Processing usually takes 10-15 business days. Submitter Name* First Last Submitter Phone Number*Submitter Email* Relation to Child*GuardianCase ManagerGALSelfChild's InformationChild's Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is the youth 18 or older?*YesNoDoes the youth have children?*YesNoYouth Phone NumberYouth Email Address Gender*FemaleMaleEthnicity*African-AmericanAsian-AmericanCaucasianHispanic-LatinoMulti-EthnicParental Rights Terminated*YesNoNot SurePlacement*Foster HomeGroup HomeRelative (not bio parent)Non-RelativeParentOtherGroup/Transitional Home*Boys TownBridging LivesCreated FamiliesDevereuxDorscher HomeFriends of Children & FamiliesFaine HouseGreat Oaks VillageImages of GloryKey HavenThe VillageOtherGrade*DaycarePre-KK123456789101112GEDCollegeNot Enrolled in SchoolSchool Currently Attending*Student ID #Only required if Enrichment Request involves direct payment to child's school. Is the case closed?*YesNoNot SureIs the case likely to close in the next 2 months?*YesNoNot SureIs this case OTI or ICPC?*OTIICPCNeitherDoes the child have a mental health diagnosis?*YesNoNot SureDoes the child have a master trust?*YesNoNot SureChild will send a "thank you" card/letter within 2 weeks of receiving services.* Yes Activity InformationActivity*AthleticsArts & CultureEducational ToolsNormalcyTransition to AdulthoodSport*BaseballBasketballCheerleadingFootballGymnasticsSoccerSwim LessonsTrack & FieldOtherArt or Cultural Activity*Art classesDance lessonsMusic lessonsOtherEducational Tool*GED prep bookLaptopTextbooksOtherNormalcy Activity*Cap & GownField TripHomecoming/PromSchool PicturesSchool UniformSenior PackageOtherTransition to AdulthoodGED TestingHousewarming BasketLaptopTextbooksApartment Application FeeDATA Course FeeDriving LessonsDrivers Permit FeeOtherWhen requesting a laptop, the young adult must type atleast one paragraph below telling us his/her educational and career goals and how having a laptop will help achieve these goals.*Activity CostHas the child been registered for this activity?*YesNoNot SurePlease describe the current need and character of the child, including how this activity would benefit them.*Activity Provider NameActivity Provider PhoneActivity Provider Email Activity Provider Website Activity Provider Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please attach all documents relevant to this request.Caregiver InformationCaregiver Name* First Last Caregiver Phone*Caregiver Email Address where child resides:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Does caregiver receive monthly funds?*YesNoNot SureCase Manager/IL Specialist InformationCase Manager Name* First Last Case Manager Phone*Case Manager Email* Case Management Agency*CHSDEVGCJFCSOHUCase Management County*Supervisor Name First Last Supervisor PhoneSupervisor Email Post Title PhoneThis field is for validation purposes and should be left unchanged.