2021 Boost Request Assistance Form

At this time, BOOST a FOSTER FAMILY only accepts referrals for Kinship families experiencing financial hardship or who have other barriers prohibiting them from becoming licensed. Questions? Please contact us here.
Type of Placement *

Kinship (hover for definition) Community/Non-Kin (BOOST is not accepting requests for Non-Kin placements at this time). Please contact Arizona Friends of Foster Care, Arizona Helping Hands or José's closet for resources.
Boost a Foster Family does not take requests for the following: rent/mortgage assistance, utilities, car repairs, appliances, home remodels, cribs, high chairs, strollers, swings, bicycles, clothing, shoes, diapers, formula, and computers. Please limit your request to items required for Arizona State Licensure.
I understand the limitations described above *
Initial Here
Licensing/DCS/ Professional's Name (hover for clarification) *

First Name Last Name
Agency/Org. Name *
Licensing Agency (DCS Case Managers - enter DCS)
Agency/DCS Location Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Licensing/DCS/ Professional's Cell Phone Number *

Area Code Phone Number
Licensing/DCS/ Professional's E-mail *
Family Information

Please provide the following data on the family in need of assistance. In order to expedite assistance, Boost is requesting identifying information. You must obtain proper permission/releases.
I have gained permission to share identifying information with Boost a Foster Family *
Primary Contact in the Family *

First Name Last Name
Is this Primary Contact English Speaking? *

Yes No
If No, what language do they speak?
Family Shipping Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Family Primary Contact email *
example@example.com
Primary Contact phone number *

Area Code Phone Number
If Kinship, Nature of Relationship *
Where is this Family in the Licensing Process *
If family is licensed explain why they are unable to use their reimbursement to cover cost of this request.
Is this family Low-Income (less than twice the federal poverty threshold) Hover for definition *

Yes No

List ALL Adults in the Home (more than 5 adults, please list data in Additional Info) *

Race/Ethnicity

Adult 1

Adult 2

Adult 3

Adult 4

Adult 5

Number of Adults over age 55 *
Number of Adults that are Veterans *
Total Number of Children in the Home *
Birth, foster, adoptive and others
Total Number of Foster Children in the Home *
Include those waiting to be placed here and below and explain in Additional Info section

List ALL Children in the Home. (more than 8 children, please list data in Additional Info) *

Race/Ethnicity

Relationship

Age

Gender

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

Child 7

Child 8

Help Needed

Qty

Comments

Car Seat (note age, weight, height, & gender in comments)

Fire Extinguisher

Smoke Alarm

CO Alarm

CO & Smoke Alarm 2 in 1 Combo

Lockable Box for Medications (note size in comments)

Lockable Bin for Toxins (cannot be shipped, must be picked up at local Home Depot)

Magnetic Cabinet Locks (note number of cabinets in QTY)

First Aid Kit

Refrigerator Locking Medicine Bag

Gun Safe (note type in comments)

Gun Trigger Locks

Tub/Shower Mat

Doctor's Physicals (list for whom in comments)

CPR/First Aid Class (list for whom in comments)

Rabies Vaccinations (PetCo eCard or Giftcard)

Dog Licenses

Ring Buoy for Pool (pool must be over 6 ft deep)

Shepherd's Hook for Pool (pool must be over 6 ft deep)

Well Water Test

Bunk Bed (kids under 6 may not be on top bunk)

Toddler Bed

Plastic Drawer Unit

Other Items/Help Needed
Where do you want items delivered?
Additional Information
Newsletter

Receive Boost Newsletters (usually sent quarterly)
Please note: We commit to responding to this referral as soon as possible. Sometimes additional information is required in order to fulfill the order. If we do not receive the requested information within 90 days, this referral will expire.
Signing your name here confirms your acceptance of Boost a Foster Family Terms and Conditions *

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Family Information