Lifebook Scholarship Form

Lifebook Scholarship Application

MN Residents ONLY
Your Name*

FirstLast
Phone*
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
How old are you now?*
Must be under 31 to get foster care records.
Race (check all that apply)*

African American/BlackAmerican Indian/Native AlaskanAsian/Pacific IslanderWhiteOther
Hispanic Heritage?*

YesNo
Gender*

MaleFemaleOther
Why do you want to start this now?*
Medical questions, reconnecting with family or friends, specific curiosity, get information to save for late
Who are your support people?*
Anyone you trust to be in your life for the next few years, has YOUR best interests at heart, and is willing to help you through this process
What types of information do you want to search out?*

Medical InformationPhotosFoster Care FileContact Information For Specific PeopleSchool Records, IEP/504/etc.Immunization ReportVital Records - SS Card, Birth, Death, Marriage, Divorce CertificateTherapy Records + EvaluationsOther
People we can reach out to (and contact info) who may have information or photos you want*
Example: Aunt Julie, 763-098-2424, example@example.com
People or time periods would you would like photos of
Example: Baby photos of me, pictures of my mom
Vital records are you interested in
Example: My birth certificate pre-adoption or my parents marriage certificate
People you'd like to connect with but don't have contact information for
Example: My fifth grade teacher Ms Jones from Johnsonville Elementary in MN
Schools you've attended and for what grades
Example: South High School, St Paul, 9-11 grades
Physical Health doctors, hospitals, clinics you've seen
Example: Born at HCMC, treated at Allina
Mental Health therapists, doctors, hospitals and clinics you've seen
Example: Saw a therapist a Fraser, his name was Robert Jones
MN County (or counties) that handled your family's foster care case, and any workers you remember
Example: Dakota County, Billy Brown was my social worker
Should be Empty:

Lifebook Scholarship Application