2024 Boost Request Assistance Form

2024 Boost Request Assistance Form
NOTE: Due to a high volume of requests, it may take a few days before your items are ordered. Please be patient with us. It helps if you fill out the form carefully and completely.

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, The Foster Alliance 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, tables, chairs, furniture, 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*
Family Information

Please provide the following data on the family in need of assistance. In order to expedite assistance, Boost is requesting identifying information. You must obtain proper permission/releases.
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 - if mailing address is different, please list address in Additional Information at bottom of the form*

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 Home or awaiting placement*
Include those waiting to be placed here and below and explain in Additional Info section

List ALL Children in the Home include those AWAITING PLACEMENT. (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 (one per bedroom and each main living space)
CO Alarm (only needed in homes with gas appliances or wood burning devices - 1 per floor)
Leave this field blank
Car Seat (MUST note age, weight, height, & gender in comments)
Lockable Box for Medications (note size in comments)
Lockable Bin for Toxins (bins will now be shipped directly to the family)
Magnetic Cabinet Locks designed for children under age 6 (note number of cabinet doors in QTY)
Refrigerator bags for medicine
Gun Safe (note type of gun in comments)
Gun Trigger Locks (no longer required by OLR but available when desired for added safety)
Dog Rabies Vaccinations -Dogs over 6mo. old
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
Exterior cabinet locks for children over age 6 (note number of cabinets in QTY)

Other Items/Help Needed
Where do you want items delivered?
CPR/First Aid & Doctor's Physical Requests

REFERRING WORKER: If requesting CPR/First Aid or Physicals, please alert that family that we will email the family within 5 days with instructions on moving forward.

	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 we will be contacting them directly.
Household Repair Requests

To request home repairs, please complete the Home Repair Form. NOTE: two estimates/bids must be submitted with this form. (For Pool Fences please submit a specific Pool Fence Request form).
Additional Information (put mailing address if different from shipping address)
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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2024 Boost Request Assistance Form

Family Information