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Alicia's Closet Family Registration Form
Welcome to Alicia's Closet! We look forward to serving your family!
Parent/Caregiver Name
*
First Name
Last Name
Second Parent/Caregiver Name (if applicable)
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
How did you hear about us?
Please Select
Agency/Organization
Social Media
Friend/Family
Online
Other
Please list name of agency, organization or person who referred you
Verification Information
**PLEASE READ CAREFULLY AND LIST "N/A" or "NONE" FOR ANY SECTIONS THAT DO NOT APPLY**
Please indicate your connection to the foster/kinship care community (please check all that apply):
*
Foster Parent
Kinship Caregiver (non-parent, primary caregiver of child(ren) who are relatives or fictive kin. Child(ren) must reside with you full time, without their biological parent)
Reunified Family (biological children were previously in foster care, eligible within 10 years of reunification date)
Former Foster Youth (young adult who was in foster care as a teen or child, eligible within 10 years of when you were in foster care/or aged out)
Adoptive Parent
FOSTER PARENTS - please list the name of your licensing agency and first & last name, email and phone number of your agency worker. (**If you are not a foster parent, please type "n/a" below **)
*
Foster parents - please upload a legible copy or photo of the placement letter from the agency or the ICCA of the child(ren) currently in your care. (*1st page and signature page only of ICCA*)
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KINSHIP CAREGIVERS - please list the name of the county you are working with, or have previously worked with. Please list "none" if you have never had court or county involvement. (**If you are not a kinship caregiver, please type "n/a" below**)
*
Kinship caregivers - please upload a legible copy or photo of your custody paperwork. (**Note: if you do not have court involvement, please upload a legible copy or photo of one of the following documents showing that you are the child's caregiver/guardian: power of attorney, school enrollment paperwork showing guardianship, medical permission document.)
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REUNIFIED FAMILIES - please list the name of the county in which your child(ren) were placed in foster care (**If you are not a reunified family, please type "n/a" below**)
*
Reunified families - please upload a legible copy or photo of your reunification paperwork stating the date you regained custody of your child(ren) or any court paperwork/communication from your caseworker.
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FORMER FOSTER YOUTH - please list the name of the county and years (approximate) that you were in foster care. Example: Franklin County, 2015-2020. (**If you are not former foster youth, please type "n/a" below**)
*
Former Foster Youth - please upload a legible copy or photo of your foster care exit paperwork, or any court paperwork, caseworker communication, etc.
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ADOPTIVE FAMILIES - please list type of adoption (foster care or kinship adoption, private adoption, international adoption, etc.) and year that each adoption was finalized. Example: John - foster care adoption, 2017. (**If you are not an adoptive family, please type "n/a" below**)
*
Child Information
**PLEASE READ CAREFULLY AND LIST "N/A" or "NONE" FOR ANY SECTIONS THAT DO NOT APPLY**
Please list first & last name and birthdate (month/day/year) of each child in your home who is currently in FOSTER CARE (example: Jane Smith 1/1/20, John Smith 3/1/23, etc.)
*
Please list first & last name and birthdate (month/day/year) of each child in your home who is currently in KINSHIP CARE (example: Jane Smith 1/1/20, John Smith 3/1/23, etc.)
*
Please list first & last name and birthdate (month/day/year) of each child in your home who is ADOPTED (example: Jane Smith 1/1/20, John Smith 3/1/23, etc.)
*
Please list first & last name and birthdate (month/day/year) of any BIOLOGICAL child in your home (you are their biological mother or father)
*
I assert that the above listed child(ren) reside in my household full time and that I am their primary caregiver
*
Yes
No
I am interested in the following Alicia's Closet programs:
Free Store
Support Group (*for Foster, Adoptive, & Kinship families only*)
Monthly Respite events ("Parents' Day Out")
Holiday Program (*Kinship & Reunified families only*)
I certify, by my signature below, that all of the above information is accurate and complete.
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