Prom Dress Appointment Request Form
This application is for Junior and Senior Displaced Foster and Relative Care Teens in any Georgia county requesting a FREE Dress Appointment to select a FREE dress wear to their High School Prom. Applications must be completed by the teen's caregiver. Applicants will be notified of their appointment date/time after their application information is verified. Dress Appointments take place in-person at the FCSF Distribution Center in Roswell, GA.
Number of Girls requesting a Free Prom Dress
*
Please Select
1
2
3
4
5
6
Total number of eligible Junior and Senior High School displaced teen girls included in this application. (Maximum 6 per form submission)
Caregiver Infomation
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
*
Street Address
City
Georgia
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County of Residence
*
Please Select
Appling
Atkinson
Bacon
Baker
Baldwin
Banks
Barrow
Bartow
Ben Hill
Berrien
Bibb
Bleckley
Brantley
Brooks
Bryan
Bulloch
Burke
Butts
Calhoun
Camden
Candler
Carroll
Catoosa
Charlton
Chatham
Chattahoochee
Chattooga
Cherokee
Clarke
Clay
Clayton
Clinch
Cobb
Coffee
Colquitt
Columbia
Cook
Coweta
Crawford
Crisp
Dade
Dawson
Decatur
DeKalb
Dodge
Dooly
Dougherty
Douglas
Early
Echols
Effingham
Elbert
Emanuel
Evans
Fannin
Fayette
Floyd
Forsyth
Franklin
Fulton
Gilmer
Glascock
Glynn
Gordon
Grady
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jeff Davis
Jefferson
Jenkins
Johnson
Jones
Lamar
Lanier
Laurens
Lee
Liberty
Lincoln
Long
Lowndes
Lumpkin
Macon
Madison
Marion
McDuffie
McIntosh
Meriwether
Miller
Mitchell
Monroe
Montgomery
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Paulding
Peach
Pickens
Pierce
Pike
Polk
Pulaski
Putnam
Quitman
Rabun
Randolph
Richmond
Rockdale
Schley
Screven
Seminole
Spalding
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Taylor
Telfair
Terrell
Thomas
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Upson
Walker
Walton
Ware
Warren
Washington
Wayne
Webster
Wheeler
White
Whitfield
Wilcox
Wilkes
Wilkinson
Worth
Your home is licensed to operate as a...
*
Foster Only
Foster to Adopt (fostering unrelated children hoping to eventually adopt)
Grandparent Raising Grandchildren (DFCS placement)
Grandparent Raising Granchildren (court or non-DFCS placement)
Relative Care (DFCS placement)
Relative Care (court or non-DFCS placement)
Non-relative Care (Fictive Kin)
Caregiver's Date of Birth
*
-
Month
-
Day
Year
Date
Is placement through a Private Agency?
*
Yes
No
Private Agency Information
Agency Name
*
Caseworker Name
*
First Name
Last Name
Caseworker Phone Number
*
Please enter a valid phone number.
Caseworker Email
*
example@example.com
Scheduling Preferences
In order to best accommodate your scheduling needs, please identify which days work best for you. When the completed appointment request form is processed, you will be assigned an appointment date and time between 3:00PM and 5:00PM
Tuesday
Wednesday
Thursday
Friday
Saturday
Back
Next
Displaced Teen #1 Information
Name
*
First Name
Last Name
What county is the teen from? (may be different than the county where you live)
*
Please Select
Appling
Atkinson
Bacon
Baker
Baldwin
Banks
Barrow
Bartow
Ben Hill
Berrien
Bibb
Bleckley
Brantley
Brooks
Bryan
Bulloch
Burke
Butts
Calhoun
Camden
Candler
Carroll
Catoosa
Charlton
Chatham
Chattahoochee
Chattooga
Cherokee
Clarke
Clay
Clayton
Clinch
Cobb
Coffee
Colquitt
Columbia
Cook
Coweta
Crawford
Crisp
Dade
Dawson
Decatur
DeKalb
Dodge
Dooly
Dougherty
Douglas
Early
Echols
Effingham
Elbert
Emanuel
Evans
Fannin
Fayette
Floyd
Forsyth
Franklin
Fulton
Gilmer
Glascock
Glynn
Gordon
Grady
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jeff Davis
Jefferson
Jenkins
Johnson
Jones
Lamar
Lanier
Laurens
Lee
Liberty
Lincoln
Long
Lowndes
Lumpkin
Macon
Madison
Marion
McDuffie
McIntosh
Meriwether
Miller
Mitchell
Monroe
Montgomery
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Paulding
Peach
Pickens
Pierce
Pike
Polk
Pulaski
Putnam
Quitman
Rabun
Randolph
Richmond
Rockdale
Schley
Screven
Seminole
Spalding
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Taylor
Telfair
Terrell
Thomas
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Upson
Walker
Walton
Ware
Warren
Washington
Wayne
Webster
Wheeler
White
Whitfield
Wilcox
Wilkes
Wilkinson
Worth
Caregiver Relationship
*
Relationship of this teen to you
Per Diem or Monthly Subsidy
*
Daily (per diem) or monthly subsidy amount ($) received by caregiver from DFCS for care of the child (please include TANF or child Social Security Benefit (SSI)amounts) or child support payment:
Race
*
African American/Black
Caucasian/White
Hispanic/Latino
Multi-Racial/Mixed
Asian
Other
Gender
*
Male
Female
We apologize,
We currently do not offer mens formalwear for this event. Thank you for your understanding!
High School Grade
*
12th Grade : Senior
11th Grade : Junior
10th Grade : Sophomore
9th Grade : Freshman
Birthdate
*
-
Month
-
Day
Year
Date
Age
*
Date Entered into Displaced Care
*
-
Month
-
Day
Year
Date
Date Entered Current Caregiver's Home
*
-
Month
-
Day
Year
Date (could be the same as the date entered into displaced care)
Have parental rights been terminated?
*
Mother
Father
Both
Neither
Do either of the child's biological parents live in the same home as the child, either part-time or full-time?
*
Yes
No
Teen's Dress Size
*
For example: 14/16, 22, 8-10,...
Does this teen have a caseworker, court liason, or kinship navigator?
*
Yes
No
Teen's Caseworker Information
This information is specific to this teen's DFCS Caseworker, Court Liason, or Kinship Navigator. Missing or incorrect information may result in a delay in obtaining an appointment.
Caseworker Name
*
First Name
Last Name
Contact Number
*
Caseworker's contact number. Please enter a valid phone number.
Email
*
Caseworker's email address. example@example.com
Displaced Teen #2 Information
Name
*
First Name
Last Name
What county is the teen from? (may be different than the county where you live)
*
Please Select
Appling
Atkinson
Bacon
Baker
Baldwin
Banks
Barrow
Bartow
Ben Hill
Berrien
Bibb
Bleckley
Brantley
Brooks
Bryan
Bulloch
Burke
Butts
Calhoun
Camden
Candler
Carroll
Catoosa
Charlton
Chatham
Chattahoochee
Chattooga
Cherokee
Clarke
Clay
Clayton
Clinch
Cobb
Coffee
Colquitt
Columbia
Cook
Coweta
Crawford
Crisp
Dade
Dawson
Decatur
DeKalb
Dodge
Dooly
Dougherty
Douglas
Early
Echols
Effingham
Elbert
Emanuel
Evans
Fannin
Fayette
Floyd
Forsyth
Franklin
Fulton
Gilmer
Glascock
Glynn
Gordon
Grady
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jeff Davis
Jefferson
Jenkins
Johnson
Jones
Lamar
Lanier
Laurens
Lee
Liberty
Lincoln
Long
Lowndes
Lumpkin
Macon
Madison
Marion
McDuffie
McIntosh
Meriwether
Miller
Mitchell
Monroe
Montgomery
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Paulding
Peach
Pickens
Pierce
Pike
Polk
Pulaski
Putnam
Quitman
Rabun
Randolph
Richmond
Rockdale
Schley
Screven
Seminole
Spalding
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Taylor
Telfair
Terrell
Thomas
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Upson
Walker
Walton
Ware
Warren
Washington
Wayne
Webster
Wheeler
White
Whitfield
Wilcox
Wilkes
Wilkinson
Worth
Per Diem or Monthly Subsidy
*
Daily (per diem) or monthly subsidy amount ($) received by caregiver from DFCS for care of the child (please include TANF or child Social Security Benefit (SSI)amounts) or child support payment:
Caregiver Relationship
*
Relationship of this teen to you (Niece, Granddaughter, Friend...)
Race
*
African American/Black
Caucasian/White
Hispanic/Latino
Multi-Racial/Mixed
Asian
Other
Gender
*
Male
Female
We apologize,
We currently do not offer mens formalwear for this event. Thank you for your understanding!
High School Grade
*
12th Grade : Senior
11th Grade : Junior
10th Grade : Sophomore
9th Grade : Freshman
Birthdate
*
-
Month
-
Day
Year
Date
Age
*
Date Entered into Displaced Care
*
-
Month
-
Day
Year
Date
Date Entered Current Caregiver's Home
*
-
Month
-
Day
Year
Date (could be the same as the date entered into displaced care)
Have parental rights been terminated?
*
Mother
Father
Both
Neither
Do either of the child's biological parents live in the same home as the child, either part-time or full-time?
*
Yes
No
Teen's Dress Size
*
For example: 14/16, 22, 8-10,...
Does this teen have a caseworker, court liason, or kinship navigator?
*
Yes
No
Teen's Caseworker Information
This information is specific to this teen's DFCS Caseworker, Court Liason, or Kinship Navigator. Missing or incorrect information may result in a delay in obtaining an appointment.
Caseworker Name
*
First Name
Last Name
Contact Number
*
Caseworker's contact number. Please enter a valid phone number.
Email
*
Caseworker's email address. example@example.com
Displaced Teen #3 Information
Name
*
First Name
Last Name
What county is the teen from? (may be different than the county where you live)
*
Please Select
Appling
Atkinson
Bacon
Baker
Baldwin
Banks
Barrow
Bartow
Ben Hill
Berrien
Bibb
Bleckley
Brantley
Brooks
Bryan
Bulloch
Burke
Butts
Calhoun
Camden
Candler
Carroll
Catoosa
Charlton
Chatham
Chattahoochee
Chattooga
Cherokee
Clarke
Clay
Clayton
Clinch
Cobb
Coffee
Colquitt
Columbia
Cook
Coweta
Crawford
Crisp
Dade
Dawson
Decatur
DeKalb
Dodge
Dooly
Dougherty
Douglas
Early
Echols
Effingham
Elbert
Emanuel
Evans
Fannin
Fayette
Floyd
Forsyth
Franklin
Fulton
Gilmer
Glascock
Glynn
Gordon
Grady
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jeff Davis
Jefferson
Jenkins
Johnson
Jones
Lamar
Lanier
Laurens
Lee
Liberty
Lincoln
Long
Lowndes
Lumpkin
Macon
Madison
Marion
McDuffie
McIntosh
Meriwether
Miller
Mitchell
Monroe
Montgomery
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Paulding
Peach
Pickens
Pierce
Pike
Polk
Pulaski
Putnam
Quitman
Rabun
Randolph
Richmond
Rockdale
Schley
Screven
Seminole
Spalding
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Taylor
Telfair
Terrell
Thomas
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Upson
Walker
Walton
Ware
Warren
Washington
Wayne
Webster
Wheeler
White
Whitfield
Wilcox
Wilkes
Wilkinson
Worth
Caregiver Relationship
*
Relationship of this teen to you (Niece, Granddaughter, Friend...)
Per Diem or Monthly Subsidy
*
Daily (per diem) or monthly subsidy amount ($) received by caregiver from DFCS for care of the child (please include TANF or child Social Security Benefit (SSI)amounts) or child support payment:
Race
*
African American/Black
Caucasian/White
Hispanic/Latino
Multi-Racial/Mixed
Asian
Other
Gender
*
Male
Female
We apologize,
We currently do not offer mens formalwear for this event. Thank you for your understanding!
High School Grade
*
12th Grade : Senior
11th Grade : Junior
10th Grade : Sophomore
9th Grade : Freshman
Birthdate
*
-
Month
-
Day
Year
Date
Age
*
Date Entered into Displaced Care
*
-
Month
-
Day
Year
Date
Date Entered Current Caregiver's Home
*
-
Month
-
Day
Year
Date (could be the same as the date entered into displaced care)
Have parental rights been terminated?
*
Mother
Father
Both
Neither
Do either of the child's biological parents live in the same home as the child, either part-time or full-time?
*
Yes
No
Teen's Dress Size
*
For example: 14/16, 22, 8-10,...
Does this teen have a caseworker, court liason, or kinship navigator?
*
Yes
No
Teen's Caseworker Information
This information is specific to this teen's DFCS Caseworker, Court Liason, or Kinship Navigator. Missing or incorrect information may result in a delay in obtaining an appointment.
Caseworker Name
*
First Name
Last Name
Contact Number
*
Caseworker's contact number. Please enter a valid phone number.
Email
*
Caseworker's email address. example@example.com
Displaced Teen #4 Information
Name
*
First Name
Last Name
What county is the teen from? (may be different than the county where you live)
*
Please Select
Appling
Atkinson
Bacon
Baker
Baldwin
Banks
Barrow
Bartow
Ben Hill
Berrien
Bibb
Bleckley
Brantley
Brooks
Bryan
Bulloch
Burke
Butts
Calhoun
Camden
Candler
Carroll
Catoosa
Charlton
Chatham
Chattahoochee
Chattooga
Cherokee
Clarke
Clay
Clayton
Clinch
Cobb
Coffee
Colquitt
Columbia
Cook
Coweta
Crawford
Crisp
Dade
Dawson
Decatur
DeKalb
Dodge
Dooly
Dougherty
Douglas
Early
Echols
Effingham
Elbert
Emanuel
Evans
Fannin
Fayette
Floyd
Forsyth
Franklin
Fulton
Gilmer
Glascock
Glynn
Gordon
Grady
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jeff Davis
Jefferson
Jenkins
Johnson
Jones
Lamar
Lanier
Laurens
Lee
Liberty
Lincoln
Long
Lowndes
Lumpkin
Macon
Madison
Marion
McDuffie
McIntosh
Meriwether
Miller
Mitchell
Monroe
Montgomery
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Paulding
Peach
Pickens
Pierce
Pike
Polk
Pulaski
Putnam
Quitman
Rabun
Randolph
Richmond
Rockdale
Schley
Screven
Seminole
Spalding
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Taylor
Telfair
Terrell
Thomas
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Upson
Walker
Walton
Ware
Warren
Washington
Wayne
Webster
Wheeler
White
Whitfield
Wilcox
Wilkes
Wilkinson
Worth
Caregiver Relationship
*
Relationship of this teen to you (Niece, Granddaughter, Friend...)
Per Diem or Monthly Subsidy
*
Daily (per diem) or monthly subsidy amount ($) received by caregiver from DFCS for care of the child (please include TANF or child Social Security Benefit (SSI)amounts) or child support payment:
Race
*
African American/Black
Caucasian/White
Hispanic/Latino
Multi-Racial/Mixed
Asian
Other
Gender
*
Male
Female
We apologize,
We currently do not offer mens formalwear for this event. Thank you for your understanding!
High School Grade
*
12th Grade : Senior
11th Grade : Junior
10th Grade : Sophomore
9th Grade : Freshman
Birthdate
*
-
Month
-
Day
Year
Date
Age
*
Date Entered into Displaced Care
*
-
Month
-
Day
Year
Date
Date Entered Current Caregiver's Home
*
-
Month
-
Day
Year
Date (could be the same as the date entered into displaced care)
Have parental rights been terminated?
*
Mother
Father
Both
Neither
Do either of the child's biological parents live in the same home as the child, either part-time or full-time?
*
Yes
No
Teen's Dress Size
*
For example: 14/16, 22, 8-10,...
Does this teen have a caseworker, court liason, or kinship navigator?
*
Yes
No
Teen's Caseworker Information
This information is specific to this teen's DFCS Caseworker, Court Liason, or Kinship Navigator. Missing or incorrect information may result in a delay in obtaining an appointment.
Caseworker Name
*
First Name
Last Name
Contact Number
*
Caseworker's contact number. Please enter a valid phone number.
Email
*
Caseworker's email address. example@example.com
Displaced Teen #5 Information
Name
*
First Name
Last Name
What county is the teen from? (may be different than the county where you live)
*
Please Select
Appling
Atkinson
Bacon
Baker
Baldwin
Banks
Barrow
Bartow
Ben Hill
Berrien
Bibb
Bleckley
Brantley
Brooks
Bryan
Bulloch
Burke
Butts
Calhoun
Camden
Candler
Carroll
Catoosa
Charlton
Chatham
Chattahoochee
Chattooga
Cherokee
Clarke
Clay
Clayton
Clinch
Cobb
Coffee
Colquitt
Columbia
Cook
Coweta
Crawford
Crisp
Dade
Dawson
Decatur
DeKalb
Dodge
Dooly
Dougherty
Douglas
Early
Echols
Effingham
Elbert
Emanuel
Evans
Fannin
Fayette
Floyd
Forsyth
Franklin
Fulton
Gilmer
Glascock
Glynn
Gordon
Grady
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jeff Davis
Jefferson
Jenkins
Johnson
Jones
Lamar
Lanier
Laurens
Lee
Liberty
Lincoln
Long
Lowndes
Lumpkin
Macon
Madison
Marion
McDuffie
McIntosh
Meriwether
Miller
Mitchell
Monroe
Montgomery
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Paulding
Peach
Pickens
Pierce
Pike
Polk
Pulaski
Putnam
Quitman
Rabun
Randolph
Richmond
Rockdale
Schley
Screven
Seminole
Spalding
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Taylor
Telfair
Terrell
Thomas
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Upson
Walker
Walton
Ware
Warren
Washington
Wayne
Webster
Wheeler
White
Whitfield
Wilcox
Wilkes
Wilkinson
Worth
Caregiver Relationship
*
Relationship of this teen to you (Niece, Granddaughter, Friend...)
Per Diem or Monthly Subsidy
*
Daily (per diem) or monthly subsidy amount ($) received by caregiver from DFCS for care of the child (please include TANF or child Social Security Benefit (SSI)amounts) or child support payment:
Race
*
African American/Black
Caucasian/White
Hispanic/Latino
Multi-Racial/Mixed
Asian
Other
Gender
*
Male
Female
We apologize,
We currently do not offer mens formalwear for this event. Thank you for your understanding!
High School Grade
*
12th Grade : Senior
11th Grade : Junior
10th Grade : Sophomore
9th Grade : Freshman
Birthdate
*
-
Month
-
Day
Year
Date
Age
*
Date Entered into Displaced Care
*
-
Month
-
Day
Year
Date
Date Entered Current Caregiver's Home
*
-
Month
-
Day
Year
Date (could be the same as the date entered into displaced care)
Have parental rights been terminated?
*
Mother
Father
Both
Neither
Do either of the child's biological parents live in the same home as the child, either part-time or full-time?
*
Yes
No
Teen's Dress Size
*
For example: 14/16, 22, 8-10,...
Does this teen have a caseworker, court liason, or kinship navigator?
*
Yes
No
Teen's Caseworker Information
This information is specific to this teen's DFCS Caseworker, Court Liason, or Kinship Navigator. Missing or incorrect information may result in a delay in obtaining an appointment.
Caseworker Name
*
First Name
Last Name
Contact Number
*
Caseworker's contact number. Please enter a valid phone number.
Email
*
Caseworker's email address. example@example.com
Displaced Teen #6 Information
Name
*
First Name
Last Name
What county is the teen from? (may be different than the county where you live)
*
Please Select
Appling
Atkinson
Bacon
Baker
Baldwin
Banks
Barrow
Bartow
Ben Hill
Berrien
Bibb
Bleckley
Brantley
Brooks
Bryan
Bulloch
Burke
Butts
Calhoun
Camden
Candler
Carroll
Catoosa
Charlton
Chatham
Chattahoochee
Chattooga
Cherokee
Clarke
Clay
Clayton
Clinch
Cobb
Coffee
Colquitt
Columbia
Cook
Coweta
Crawford
Crisp
Dade
Dawson
Decatur
DeKalb
Dodge
Dooly
Dougherty
Douglas
Early
Echols
Effingham
Elbert
Emanuel
Evans
Fannin
Fayette
Floyd
Forsyth
Franklin
Fulton
Gilmer
Glascock
Glynn
Gordon
Grady
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jeff Davis
Jefferson
Jenkins
Johnson
Jones
Lamar
Lanier
Laurens
Lee
Liberty
Lincoln
Long
Lowndes
Lumpkin
Macon
Madison
Marion
McDuffie
McIntosh
Meriwether
Miller
Mitchell
Monroe
Montgomery
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Paulding
Peach
Pickens
Pierce
Pike
Polk
Pulaski
Putnam
Quitman
Rabun
Randolph
Richmond
Rockdale
Schley
Screven
Seminole
Spalding
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Taylor
Telfair
Terrell
Thomas
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Upson
Walker
Walton
Ware
Warren
Washington
Wayne
Webster
Wheeler
White
Whitfield
Wilcox
Wilkes
Wilkinson
Worth
Caregiver Relationship
*
Relationship of this teen to you (Niece, Granddaughter, Friend...)
Per Diem or Monthly Subsidy
*
Daily (per diem) or monthly subsidy amount ($) received by caregiver from DFCS for care of the child (please include TANF or child Social Security Benefit (SSI)amounts) or child support payment:
Race
*
African American/Black
Caucasian/White
Hispanic/Latino
Multi-Racial/Mixed
Asian
Other
Gender
*
Male
Female
We apologize,
We currently do not offer mens formalwear for this event. Thank you for your understanding!
High School Grade
*
12th Grade : Senior
11th Grade : Junior
10th Grade : Sophomore
9th Grade : Freshman
Birthdate
*
-
Month
-
Day
Year
Date
Age
*
Date Entered into Displaced Care
*
-
Month
-
Day
Year
Date
Date Entered Current Caregiver's Home
*
-
Month
-
Day
Year
Date (could be the same as the date entered into displaced care)
Have parental rights been terminated?
*
Mother
Father
Both
Neither
Do either of the child's biological parents live in the same home as the child, either part-time or full-time?
*
Yes
No
Teen's Dress Size
*
For example: 14/16, 22, 8-10,...
Does this teen have a caseworker, court liason, or kinship navigator?
*
Yes
No
Teen's Caseworker Information
This information is specific to this teen's DFCS Caseworker, Court Liason, or Kinship Navigator. Missing or incorrect information may result in a delay in obtaining an appointment.
Caseworker Name
*
First Name
Last Name
Contact Number
*
Caseworker's contact number. Please enter a valid phone number.
Email
*
Caseworker's email address. example@example.com
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