Facility Use Request Mat-Su Family Support Center

Facility Use Request Form
What are you requesting to use the Family Support Center for?*

Family Contact / VisitationEventTidy Team

Tidy Team Request Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date

MonthDayYear
Date
Time requested

Starting after 8:00am

AM/PM Option

Until
until
Done before 8:00pm

AM/PM Option
Comments

Event Request Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date

MonthDayYear
Date
Time requested (including prep and clean-up)

Starting after 8:00am

AM/PM Option

Until
until
Done before 8:00pm

AM/PM Option
Group / Organization
Purpose of Event
Comments

Family Contact Request Form
All Family Contact must be supervised by a responsible party approved by the Office of Children's Services caseworker. A Family Contact supervising party could be a professional Family Contact Facilitator working for an agency, an approved Relative, Foster Parent or Community Volunteer. Once approved by the caseworker, this request form should be filled out preferably by, but can be on behalf of, the person responsible for supervising the Family Contact.
Family Time Supporter / Family Contact Facilitator
Facilitator / Supporter Name*

First NameLast Name
Facilitator / Supporter Phone Number*
Mobile phone with texting preferred
Facilitator / Supporter Email*
example@example.com
The approved party responsible for this Family Contact is a:*
My role is ...
What agency do you work for? *
Agency
What Tribe are you affiliated with? *
Agency
What is your job title? *
Job title
What is your relationship to the child(ren)? *
example: paternal grandma, maternal uncle, cousin
What is your relationship to the family? *
examples: family friend, community volunteer
Office of Children's Services Caseworker

Caseworker pre-approval is required for requesting use of the facility.
OCS Caseworker Name*
OCS Caseworker Phone Number
Please enter a valid phone number.
OCS Caseworker Email*
example@example.com
This OCS Caseworker has approved the Facilitator/Supporter listed above to supervise family contact for this family.

yesno
Request Scheduling Details

Dates and times requested are subject to availability and requests are not secured until a confirmation email is received.
Reoccurring Start Date Request

MonthDayYear
Date
Reoccurring Day requested

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Reoccurring Time requested

Starting after 8:00am

AM/PM Option

Until
until
Done before 8:00pm

AM/PM Option
Would you like to request regularly repeating visits?

Yes
One-Time Facility Use Date Request

MonthDayYear
Date
One-Time Facility Use Time requested

Starting after 8:00am

AM/PM Option

Until
until
Done before 8:00pm

AM/PM Option
Repeating
Comments/Notes/List of Multiple One-Time Facility Use Request dates
Family Demographic Information

Adults participating in Family Contact:
Adult 1 Name*

First NameLast Name
Adult 1 Relationship to child*
Adult 1 Please describe relationship *
Adult 1 Residence*
Adult 1 Other Residence *
Adult 1 Age *
Additional Adults?

YES
Adult 2 Name*

First NameLast Name
Adult 2 Relationship to child*
Adult 2 Please describe relationship *
Adult 2 Residence*
Adult 2 Other Residence *
Adult 2 Age *
Additional Adults?

YES
Adult 3 Name*

First NameLast Name
Adult 3 Relationship to child*
Adult 3 Please describe relationship *
Adult 3 Residence*
Adult 3 Residence *
Adult 3 Age *
Children participating in Family Contact:
Child 1 Gender *
Child 1 Age*
Additional children?

YES
Child 2 Gender *
Child 2 Age*
Additional children?

YES
Child 3 Gender *
Child 3 Age*
Additional children?

YES
Child 4 Gender *
Child 4 Age*
Additional children?

YES
Child 5 Gender *
Child 5 Age*
Additional children?

YES
Child 6 Gender *
Child 6 Age*
By submitting this facility request form, I agree that all information provided is accurate to the best of my knowledge and that the OCS Caseworker has approved the requested family contact and Family Contact Facilitator / Family Time Supporter.
Should be Empty:

Facility Use Request Form

Tidy Team Request Form

Event Request Form

Family Contact Request Form

Family Time Supporter / Family Contact Facilitator

Office of Children's Services Caseworker

Request Scheduling Details

Family Demographic Information