2024 General Funding Request Form

Date of Request*

MonthDayYear

Applicant First Name*

Applicant Last Name*

E-mail*

Confirmation Emailexample@example.com

Direct Phone#*

Area CodePhone Number

What is your role in the child's life?*

Is the child assigned to the Guardian ad Litem Program?*

GAL Assigned to Case*

GAL Email*

Please don't put your email

CAM/CAMII*

Please don't put your name

CAM/CAMII Email*

Please don't put your email

Dependency Case Manager (ChildNet)*

Please don't put your name

Dependency Case Manager (ChildNet) Email*

Please don't put your email

Who is the Magistrates or Judge assigned to your case*

Case Number*

Child's First Name*

Child's Last Name*

Child's Gender*

Child's DOB*

Child's Race/Ethnicity*

Placement Type*

Name of Group Home or Foster Care Organization *

How long has the child been in current placement?

Placement stability: How confident are you in the stability of this placement?

City child resides in*

County child resides in*

County*

Does the child have other siblings in care?*

What are the names and ages of siblings in care?

Please be sure to submit a separate funding request if a sibling(s) also have a need

Does the family receive any of the below funds?*

Please select all that apply. Press Ctrl Key to select more than one.

Request Category*

Educational Need*

Describe the Emergency Need*

Please make sure this need doesn't fit into another category (i.e. Parent/Relative/Non Relative Caregiver Need

Basic Essential Need*

Clothing, Baby Items, Hygiene, Bedding, etc.

Normalcy Need*

Social/Emotional Need (Max funding availability is $200 per child per year.)

Parent/Relative/Non Relative Caregiver Need*

Funding support to provide placement stability or reunification with relative, non relative, or biological parent(s)

Transportation Need*

The Linda Saraniti Fine Arts Fund*

This category is for music, theatre, arts, and other fine arts (max funding availability is $200 per child per year).

What other transportation need are you seeking*

What is the level of need*

Describe the need. Please explain in as much detail as possible:*

Amount Requested*

Type of Payment*

Select where online*

Link:*

Select Type of Gift Card*

What other gift card:*

Who Should Check By Made Out to:*

(Will only be cut if all support documentation is provided and will directly be sent to provider. Reimbursements will not be provided to anyone)

Address to where the check should be mailed

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is the other payment option you are seeking:*

(Only select this option if there is absolutely no other way to fulfill request. This includes payment to a provider by credit card, other store gift card, etc. Reimbursements will not be provided to anyone)

If applicable, please attach invoice or receipt:

Any additional comments that can help Voices in making a decision:

You agree to schedule a staffing meeting, using the link in the confirmation email, with the Vice President of Programs once this form is submitted. You understand that failure to schedule staffing will automatically decline this request.*

You agree to provide a follow up report within 60 days after approval of funding. You understand that applicants with follow up reports outstanding will not be able to submit new requests until the follow up report is completed.*

General Referral Funding Request Form