General Referral Funding Request Form
Date of Request
*
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Month
-
Day
Year
Date Picker Icon
Applicant First Name
*
Applicant Last Name
*
E-mail
*
Confirmation Email
example@example.com
Direct Phone#
*
-
Area Code
Phone Number
What is your role in the child's life?
*
Please Select
Guardian ad Litem
CAM
Guardian ad Litem Attorney
ChildNet DCM
Caregiver
Other
Is the child assigned to the Guardian ad Litem Program?
*
Please Select
Yes
No
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
*
Please Select
Magistrate Boven
Magistrate Plant
Judge Bristol
Judge Gamm
Judge Izquierdo
Judge Ribas
Judge Schulman
Not assigned a Magistrate or Judge
Case Number
*
Child's First Name
*
Child's Last Name
*
Child's Gender
*
Please Select
Female
Male
Nonbinary
Transgender
Child's DOB
*
Child's Race/Ethnicity
*
Please Select
Black/African American
Biracial/Multiple Racial
Hispanic or Latino
White Non-Latino/Caucasian
Asian
American Indian/Alaska Native
Native Hawaiian and Other Pacific Islander
Other
Placement Type
*
Please Select
Foster Parent
Relative Caregiver
Non-Relative Caregiver
Foster Care Organization
Group Home
In Home or Reunified
Aged Out Youth
Name of Group Home or Foster Care Organization
*
How long has the child been in current placement?
Please Select
0-6 months
6-12 months
1-3 years
More than 3 years
Placement stability: How confident are you in the stability of this placement?
Please Select
Very Confident
Confident
Somewhat Confident
Unsure
Not Confident
City child resides in
*
County child resides in
*
Please Select
Broward
Miami-Dade
Palm Beach
Other
County
*
Does the child have other siblings in care?
*
Please Select
No
Yes, and they live together
Yes, but they don't live together
Not sure
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?
*
Relative Funds
Non-Relative Funds
Food Stamps
Other Assistance (child support, social security, etc.)
Doesn't receive any of the above
Please select all that apply. Press Ctrl Key to select more than one.
Request Category
*
Please Select
Educational Need
Emergency Need
Basic Essential Need (clothing, baby items, hygiene, bedding, etc.)
Normalcy Need (Social/Emotional Need)
Parent (if child lives with parent)/Relative/Non Relative Caregiver Need
Transportation Need
The Linda Saraniti Fine Arts Fund
Educational Need
*
Please Select
School Supplies and Uniforms are not available at this time
Graduation Fees
School Field Trip
Tutoring
Fees or Costs Associated with Attending School (daycare, tuition, GED, etc.)
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
*
Please Select
Clothing
Shoes
Underwear
Mattress
Bedding (sheets, pillows, blanket)
care items
Hygiene Items
Baby Stroller
Baby Car Seat
Diapers and Wipes
Medical (not covered by Medicaid)
Clothing, Baby Items, Hygiene, Bedding, etc.
Normalcy Need
*
Please Select
Extracurricular/Club Activity (not a sport or wellness activity, which would qualify under The Luke Hoyer Athletic Fund)
School Special Event (homecoming, prom, etc.)
Yearbook
Grad Pics
Other (toys, art supplies, games, etc.)
Women's or Men's Haircut/Hair Accessories or Supplies/Makeup
Social/Emotional Need (Max funding availability is $200 per child per year.)
Parent/Relative/Non Relative Caregiver Need
*
Please Select
Emergency Expense
Home Study Needs
Funding support to provide placement stability or reunification with relative, non relative, or biological parent(s)
Transportation Need
*
Please Select
Bus Pass
Brightline Pass
Tri-Rail Pass
Other
The Linda Saraniti Fine Arts Fund
*
Please Select
Instruments and/or music equipment
Music lessons
Singing lessons
Theatre training and/or performance(s)
Acting classes
Art classes and related activities
TV and/or multi-media
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
*
Please Select
Significant need for help
Caregiver(s) doing ok, but could use some help
I would like to purchase this regardless of need
Request prompted by caregiver
I don't know
Describe the need. Please explain in as much detail as possible:
*
Amount Requested
*
Type of Payment
*
Please Select
Online Purchase
Gift Card
Check
Other
Select where online
*
Please Select
Amazon
Walmart
Target
Other
Link:
*
Select Type of Gift Card
*
Please Select
Publix
Target
Walmart
Other
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
City
State / 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.
*
Please Select
Yes, I agree and understand
No, I don't agree
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.
*
Please Select
Yes, I agree and understand
No, I don't agree
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