Summer Camp Request Form 2022 - Foundation for Foster ChildrenFoundation for Foster Children

Summer Camp Criteria

Does student resides in Orange County?*

Yes
No

Summer camps must fall between May 26th and August 9th.*

I understand. My chosen summer camp falls between these dates.

Due to limited funding, requests for camps for more than $250, specialty/therapeutic camps, or sleep-away/overnight camps may not be approved.*

My chosen summer camp is less than $250 and it's not a specialty/therapeutic or sleep-away/overnight camp.
My chosen summer camp is more than $250

Has child's registration for camp been submitted to vendor?*

Yes
No

Please pre-register the child or youth prior to submitting. Do not submit this form for now. Please follow instructions below and come back when you are ready!

Please contact the Summer Camp of your choice and register your student for the dates that you want them to participate. Explain the camp that the payment will be made by a third party and that the Foundation for Foster Children will call them in the next few days to make the payment on you behalf. Once you have registered the student, you can complete this form for us to make the payment. Thank you!

We need some additional information. If the camp is more than $250 or the child requires more than one (1) week for caregiver work purposes or other circumstances, please complete the form below and this will be reviewed by Embrace Families’ Network Resources staff prior to approval.

Student Name (Over $250)*

First Last

Student Date of Birth (Over $250)*

Does the child have a mental health diagnosis?*

Yes
No
Unsure

Submitter Name (Over $250)*

First Last

Submitter Phone (Over $250)*

Submitter Email (Over $250)*

County where student resides (Over $250)*

If other, please specify (Over $250)*

Is there a stay-at-home caregiver in the child's placement? (Over $250)*

Summer Camp Name (Over $250)*

Summer Camp Address (Over $250)*

Street Address Address Line 2 City State ZIP Code

Summer Camp Start Date*

Please select the start date of the one week requested

Summer Camp End Date*

How many weeks would you like to request? (Over $250)*

Please specify the exact cost of ONE week of camp.*

Submitter Information

Submitter Name*

First Last

Submitter Phone Number*

Submitter Email*

Relation to Child*

Student Information

Student Name*

First Last

Please specify if the student is the foster or bio child*

FSFN Person ID

Date of Birth*

Gender*

Female
Male
Nonbinary
Other

If other, please specify*

Ethnicity*

African-American
Asian-American
Caucasian
Hispanic-Latino
Multi-Ethnic

Parental Rights Terminated*

Yes
No
Not Sure

Placement*

Foster Home
Group Home
Relative (Not Bio Parent)
Non-Relative Parent
Other

Address where child resides:*

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

County of Residence*

If other, please specify*

Grade*

School Currently Attending*

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

Yes
No
Not Sure

Is this case OTI or ICPC?*

OTI
ICPC
Neither

Does the child have a master trust fund?*

Yes
No
Not Sure

Does the child have a mental health diagnosis?*

Yes
No
Unsure

Has a CMH/FSPT packet been completed? (for case management only)*

Yes
No
Unknown

Caregiver Information

Caregiver Name*

First Last

Caregiver Phone*

Caregiver Email*

Case Manager/IL Specialist Information

Case Manager Name*

First Last

Case Manager Phone*

Case Manager Email*

Case Management Agency*

Case Management County*

Summer Camp Information

Name of Camp*

Camp Phone Number*

Camp Email*

Camp Website*

Camp Address (Address to mail check)*

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

Please attach Camp Registration

Max. file size: 50 MB.

Please specify the exact cost of one week of camp.*

Is there a stay-at-home caregiver in the child's placement?*

Do you have a letter, flyer and/or invoice stating cost of the camp?*

Yes
No

Please attach a letter, flyer, or invoice stating costs here.*

Max. file size: 50 MB.

Start Date*

Please select the start date of the one week requested

End Date*

Are there any field trips during this camp?*

Yes
No

Please provide the cost of all field trips during the one week chosen*

Who will transport child to and from camp?

First Last

Please specify transporter relation to the youth*

Transporter's Cell Number*

Enter any additional questions or comments here

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.

Date*

Youth Name*

First Last

Youth Email*

Date of Birth*

For youth 0-17, have parental rights been terminated?*

Yes
No
Unknown
N/A: Youth is 18 or older

Relation to the Youth*

Self (Youth over 18)
Caregiver
IL Specialist/TSS
Case Manager/Caregiver Support
GAL

Photo/Testimony 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: Media/Photo Consent Form and Testimonies*

Please type first and last name

Electronic Signature: Media/Photo Consent Form and Testimonies*

By checking this box you accept this electronic signature.

Summer Camp 2022

Summer Camp Criteria

Please pre-register the child or youth prior to submitting. Do not submit this form for now. Please follow instructions below and come back when you are ready!

We need some additional information. If the camp is more than $250 or the child requires more than one (1) week for caregiver work purposes or other circumstances, please complete the form below and this will be reviewed by Embrace Families’ Network Resources staff prior to approval.

Submitter Information

Student Information

Caregiver Information

Case Manager/IL Specialist Information

Summer Camp Information

Media/Photo Consent Form and Testimonies