Georgia Kinship Project Inc. Resource Application
NOTE: This application is for relative caregivers ONLY! A relative caregiver is a parent either temporarily or permanently caring for a relative child. Relative caregivers may include: Grandparents, Aunts/Uncles, Cousins, Siblings, Step Parents, etc.
Primary Caregiver Name:
*
First Name
Last Name
Secondary Caregiver Name
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian's Phone Number:
*
-
Area Code
Phone Number
Secondary Phone Number
-
Area Code
Phone Number
Guardian's Email Address:
*
Secondary Email Address
example@example.com
Caregiver Financial Information
Please complete this section in its entirety.
Primary Caregiver's Employer
*
If unemployed, please indicate in the answer section.
Secondary Caregiver's Employer
If unemployed, please indicate in the answer section.
Primary Caregiver's Salary
*
Please indicate by annual or net monthly wage.
Secondary Caregiver's Salary
Please indicate by annual or net monthly wage.
Civil Status
*
Single
Married
Divorced
Widowed
What is your residential status?
*
Rent
Own
Living with Family
Living with Friends
Homeless
How much is your rent or mortgage?
*
Are you in need of housing assistance? If so, please describe you needs below.
*
Yes
No
Details of residential needs.
*
Are the children eligible for free or reduced lunch?
*
Yes
No
Does the primary caregiver have health insurance? If not, do you need assistance obtaining health insurance?
*
Do the children have healthcare coverage/ insurance? If not, do you need assistance obtaining coverage?
*
Are you receiving any financial assistance (i.e. TANF, SNAP, Medicaid, Public Housing, etc.)? Please describe which services you are receiving.
*
Are you receiving child support?
*
Yes
No
Does the child’s biological parents reside (one or both) with the kin caregiver?
*
Yes
No
Other
Does the child/children's biological parents provide any financial assistance?
*
Child Information
Please describe each child's name, age, and needs.
Relationship to Child/Children:
*
How many relative children reside in the home?
*
Don't include your biological children.
Child #1 Full Name:
*
Child Age
*
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child Gender
*
Male
Female
Nonbinary
Other
Child Race/ Ethnicity
*
American Indian or Alaska Native
Asian
African-American or Black
Hispanic or Latino
Native Hawaiian or Pacific Islander
Caucasian or White
Multi-Race (Describe multiple races below)
Other
Description of Multiple Races
Is this child in foster care?
*
Which County? If not in Georgia, which sending state?
*
Is this a temporary placement?
*
Child #2 Name:
Child Age:
Child's Date of Birth
-
Month
-
Day
Year
Date
Child Gender
Male
Female
Nonbinary
Other
Child Race/ Ethnicity
American Indian or Alaska Native
Asian
African-American or Black
Hispanic or Latino
Native Hawaiian or Pacific Islander
Caucasian or White
Multi-Race (Describe multiple races below)
Other
Description of Multiple Races
Is this child in foster care?
Which County? If not in Georgia, which sending state?
Is this a temporary placement?
Child #3 Name:
Child Age:
Child's Date of Birth
-
Month
-
Day
Year
Date
Child Gender
Male
Female
Nonbinary
Other
Child Race/ Ethnicity
American Indian or Alaska Native
Asian
African-American or Black
Hispanic or Latino
Native Hawaiian or Pacific Islander
Caucasian or White
Multi-Race (Describe multiple races below)
Other
Description of Multiple Races
Is this child in foster care?
Which County? If not in Georgia, which sending state?
Is this a temporary placement?
Child #4 Name:
Child Age:
Child's Date of Birth
-
Month
-
Day
Year
Date
Child Gender
Male
Female
Nonbinary
Other
Child Race/ Ethnicity
American Indian or Alaska Native
Asian
African-American or Black
Hispanic or Latino
Native Hawaiian or Pacific Islander
Caucasian or White
Multi-Race (Describe multiple races below)
Other
Description of Multiple Races
Is this child in foster care?
Which County? If not in Georgia, which sending state?
Is this a temporary placement?
Child #5 Name:
Child Age:
Child's Date of Birth
-
Month
-
Day
Year
Date
Child Gender
Male
Female
Nonbinary
Other
Child Race/ Ethnicity
American Indian or Alaska Native
Asian
African-American or Black
Hispanic or Latino
Native Hawaiian or Pacific Islander
Caucasian or White
Multi-Race (Describe multiple races below)
Other
Description of Multiple Races
Is this child in foster care?
Which County? If not in Georgia, which sending state?
Is this a temporary placement?
Case and Legal Status
Please indicate the services requested and if there is DFCS involvement, please indicate by acknowledging the case manager and the county where there is a DFCS case.
Is this a formal or informal kinship placement?
*
Formal
Informal
DFCS Case Manager Name
First Name
Last Name
DFCS Case Manager Phone Number
-
Area Code
Phone Number
DFCS Case Manager Email Address
example@example.com
Kinship Navigator/ Referrer Name
*
First Name
Last Name
Email
*
example@example.com
If DFCS is involved, which county oversees the case?
Which county do you reside in?
*
Which DFCS Region is this case in?
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Referral Needs
*
Counseling/ Therapy/ CCFAs
Behavioral Health
Pediatric Healthcare (Glasses, Dental/Braces, Hearing Aids)
Adult Healthcare (Non-Insured)
Mentorship
Child Care/ After-School Care/ Summer Camp
Food Assistance / Summer Food Program
Personal Care (Hygiene Products, Menstrual Products)
College/ Post-Secondary Education/ Military/ Independent Living
Clothing Assistance
School Supplies
Car Seat and Safety Tools
CPR/ Continuing Education
Please describe the child/ family needs. Please provide as much detail as possible.
*
If requesting clothing, would you like for it to be shipped or are you able to drive to Atlanta to shop and pick up?
*
Mail Order (The agency shops for the children)
Pick-Up (I can shop for the children. Must reside in the Metro Atlanta area.)
Do you understand that if you are picking up, the children must stay at home due to COVID restrictions? This applies ONLY to clothing shopping and not furniture or other pick-ups.
*
Yes
No
Please select the items you need from the Outreach Closet. Select all that apply.
Car Seat
Crib/Bassinet
Walker/Bouncer
Twin/Full Bed
School Supplies
Diapers/Wipes
Bottles/Sippy Cups
Comforter/ Sheets/ Bedding
College/Secondary Education Resources
Other
The Georgia Kinship Project Outreach Closet is located in Warner Robins, GA. Are you able to pick up from this location?
*
Where did you learn about Georgia Kinship Project?
*
Submit
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