Safe Families for Children Request for Help
Safe Families is a program of Lutheran Community Services Northwest
Name of Parent/Caregiver
First Name
Last Name
Email of Parent/Caregiver
example@example.com
Phone Number of Parent/Caregiver
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Other
Prefer not to answer
Race
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Caucasian/White
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
Two or more races
Other
Language Spoken
Please Select
English
Spanish
Other
Do you share legal custody with someone else?
Yes
No
2nd Parent's Name
First Name
Last Name
Email of 2nd Parent
example@example.com
Phone Number of 2nd Parent
Please enter a valid phone number.
Date of Birth of 2nd Parent
-
Month
-
Day
Year
Date
Gender of 2nd Parent
Male
Female
Other
Prefer not to answer
Race of 2nd Parent
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Caucasian/White
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
Two or more races
Other
Language Spoken of 2nd Parent
Please Select
English
Spanish
Other
Are you experiencing homelessness?
Yes
No
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you completing this for on behalf of yourself or someone else?
Myself
Someone else
Referring Organization (if applicable)
Please Select
WICAP/Project LAUNCH
WCA
Volunteer
Self-referral
school/youth facility
Nampa Family Justice Center
Mental Health Provider
Jesse Tree
Hospital/Clinic
Homeless Shelter
Federation of Families
Family / Friend
Family Advocates
Faces of Hope
Domestic Violence Shelter
DHW-other
DHW-Navigations
DHW- CPS
Community Services
Church
CATCH
Casey Family
Ada County Victims Services
Referring organization contact name
Referring organization email
example@example.com
Referring organization phone
Please enter a valid phone number.
Urgency of assistance:
Please Select
Unknown
Within the next month
Within the next week
Urgent - Needed now
Information only
Reason for assistance:
Child's Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Child's Gender
Male
Female
Child's Race
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Caucasian/White
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
Two or more races
Other
Do you have another child?
Yes
No
Child 2 Name
First Name
Last Name
Child 2 Date of Birth
-
Month
-
Day
Year
Date
Child 2 Gender
Male
Female
Child 2 Race
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Caucasian/White
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
Two or more races
Other
Do you have another child?
Yes
No
Child 3 Name
First Name
Last Name
Child 3 Date of Birth
-
Month
-
Day
Year
Date
Child 3 Gender
Male
Female
Child 3 Race
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Caucasian/White
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
Two or more races
Other
Do you have another child?
Yes
No
Child 4 Name
First Name
Last Name
Child 4 Date of Birth
-
Month
-
Day
Year
Date
Child 4 Gender
Male
Female
Child 4 Race
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Caucasian/White
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
Two or more races
Other
Do you have another child?
Yes
No
Child 5 Name
First Name
Last Name
Child 5 Date of Birth
-
Month
-
Day
Year
Date
Child 5 Gender
Male
Female
Child 5 Race
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Caucasian/White
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
Two or more races
Other
Do you have another child?
Yes
No
Child 6 Name
First Name
Last Name
Child 6 Date of Birth
-
Month
-
Day
Year
Date
Child 6 Gender
Male
Female
Child 6 Race
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Caucasian/White
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
Two or more races
Other
Do you have another child?
Yes
No
Child 7 Name
First Name
Last Name
Child 7 Date of Birth
-
Month
-
Day
Year
Date
Child 7 Gender
Male
Female
Child 7 Race
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Caucasian/White
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
Two or more races
Other
Do you have another child?
Yes
No
Child 8 Name
First Name
Last Name
Child 8 Date of Birth
-
Month
-
Day
Year
Date
Child 8 Gender
Male
Female
Child 8 Race
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Caucasian/White
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
Two or more races
Other
Do you have another child?
Yes
No
Child 9 Name
First Name
Last Name
Child 9 Date of Birth
-
Month
-
Day
Year
Date
Child 9 Gender
Male
Female
Child 9 Race
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Caucasian/White
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
Two or more races
Other
Do you have another child?
Yes
No
Child 10 Name
First Name
Last Name
Child 10 Date of Birth
-
Month
-
Day
Year
Date
Child 10 Gender
Male
Female
Child 10 Race
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Caucasian/White
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
Two or more races
Other
Name of person completing this form:
First Name
Last Name
Submit
Should be Empty: