The School Break Food & Wellness Program
The Luke Hoyer Athletic Fund
Date of Request
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Month
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Day
Year
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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 DOB
*
Child's Gender
*
Please Select
Female
Male
Nonbinary
Transgender
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
Does the family receive any of the below funds?
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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
Food Assistance
The Luke Hoyer Athletic Fund
Food Assistance Need
*
Please Select
Emergency Food Assistance
Holiday Dinner
School Vacation: Thanksgiving
School Vacation: Winter Break
School Vacation: Spring Break
Summer Meals
The Luke Hoyer Athletic Fund
*
Registration Fees
Equipment
Sneakers/Other Shoes
Clothing for Activity
Other
Describe the other need you are seeking
*
This includes other costs that might not be listed above that is associated with the activity
Describe the need. Please explain in as much detail as possible:
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Amount Requested
*
Type of Payment
*
Please Select
Online Purchase/Registration
Check
Instacart/Other Food Delivery
Other
Select where online
*
Please Select
Online Registration Form
Amazon
Walmart
Target
Other
Link:
*
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)
How many live in the household? Please include the names and ages of any children that live in household.
*
Do any of the children have allergies
*
Please Select
Yes
No
List any allergies:
*
Address to where the check should be mailed
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of person who will be receiving Instacart/other food delivery:
*
Address to where the Instacart/ther food should be delivered
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number for Instacart delivery
*
-
Area Code
Phone Number
What is the other payment option you are seeking:
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(Only select this option if there is absolutely no other way to fulfill request. This includes payment to a provider by credit card or another way. Reimbursements will not be provided to anyone)
Describe the sport or wellness activity child wants to participate in
*
Has this child ever participate in this sport or wellness activity in the past
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Please Select
Yes
No
Do you need Voices to help with the selection of a program, coach, team, etc.
*
Please Select
Yes
No
Why did the child select this sport or wellness activity
*
How will the child get to the sport or wellness activity
*
How will participating in this sport or wellness activity help child
*
How will the funding be sustained so the child can continue with the sport or wellness activity
*
If applicable, please attach invoice or receipt:
Upload a File
Cancel
of
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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