2023 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.Reunification (BOOST will consider assisting a family reunifying on a case by case basis)

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.

Boost a Foster Family does not take requests directly from families. If you are a foster parent needing assistance, please contact your caseworker or licensing worker.

I understand the limitations described above*

Initial Here

Licensing/DCS/Care Portal Worker's Name (hover for clarification)*

First NameLast Name

Select Agency Office*

If not listed above please list Agency name and address

Leave blank if the address in the drop down list above is correctly listed.

Licensing/DCS/Care Portal Worker's Cell Phone Number*

Area CodePhone Number

Licensing/DCS/Care Portal Worker's E-mail*

I have gained permission to share identifying information with Boost a Foster Family **

Name of Primary Contact in the Family*

First NameLast Name

Is this Primary Contact English Speaking?*

YesNo

If No, what language do they speak?

Family Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

AZ County of Residence

Family Primary Contact email *

DO NOT PUT WORKER's EMAIL (if family does not have email state "none")

Family Primary Contact phone number*

Area CodePhone Number

If Kinship, Nature of Relationship*

What best describes the family's situation?*

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*

YesNo

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 60*

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:

If requesting a CAR SEAT you MUST add requested information to the COMMENTS section of this table. Without that info, your request may not be filled in a timely manner.

Item List:

	Qty	Comments
First Aid Kit
Tub/Shower Mat
Fire Extinguisher
Smoke Alarm
CO Alarm (only needed in homes with gas appliances or wood burning devices)
CO & Smoke Alarm 2 in 1 Combo
Car Seat (MUST note age, weight, height, & gender in comments)
Lockable Box for Medications (note size in comments)
Lockable Bin for Toxins (must be picked up by worker at local Home Depot - provide preferred location in comments)
Magnetic Cabinet Locks (note number of cabinets in QTY)
Refrigerator Locking Medicine Bag
Gun Safe (note type of gun in comments)
Gun Trigger Locks (no longer required by OLR but available when desired for added safety)
Rabies Vaccinations (PetCo eCard or Giftcard)
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 age 6 may not be on top bunk)
Toddler Bed (note if a mattress is needed in comments)
Plastic Drawer Unit
Outlet Covers

Other Items/Help Needed (list home repair items below)

Where do you want items delivered?

Lockable Bin for Toxins must be picked up by worker at local Home Depot - note location above in comment section.

CPR/First Aid & Doctor's Physical Requests

REFERRING WORKER: If requesting CPR/First Aid or Physicals, please alert that family that we will email them a form to be completed within 5 days, and the family must schedule their appointment within 30 days. If the family is not ready, feel free to put in a request at a later day.

Many factors are taken into consideration when scheduling caregivers for these services. Please DO NOT tell your client they will get to have classes or a physical done in a certain manner. This will be determined by the Boost Project Manager and the team of service providers and then be offered to the family. Thank you for your cooperation and understanding.

	QTY	Comments
Doctor's Physicals
CPR/First Aid Classes

Verify for CPR & Physicals Requests

By clicking here, I verify I have contacted the family to alert them that they must complete the referral form within 5 days and schedule an appointment within 30 days.

Household Repair Requests

Boost a Foster Family will assist with minor home repairs required for placement of a child or required to pass the Life Safety Inspection. (For Pool Fences please submit a specific Pool Fence Request form).

Boost will ONLY provide assistance to families for the following when the primary care giver is unable to do the work themselves due to physical or financial limitations. Please explain the family’s situation in the comments section.

Household Repair:

	QTY	Comments
Window Replacement/Repair
Door Replacement/Repair
Electrical Assistance (ie: for exposed wires)
Plumbing Assistance
Yard Clean Up/Removal of Unsafe Items

Other Household Repairs Needed

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 30 days, this referral will expire.

Signing your name here confirms your acceptance of Boost a Foster Family Terms and Conditions *

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2023 Boost Request Assistance Form

Family Information