2026 LIFT Request Form

  • !FOR COMMUNITY PARTNER USE ONLY! PLEASE DO NOT FORWARD THIS LINK TO CLIENTS. IF YOU ARE A CLIENT, PLEASE CONNECT BACK WITH YOUR RESOURCE WORKER AS YOUR REQUEST WILL BE DENIED. 

  • Yamhill County Local Integration Family Team (LIFT) is partnering with Systems of Care (SOC) to administer agile funding. Funds will be available on a first come first served basis after the following criteria has been met. Funds are available until they run out.
    In order to create ample funding opportunity to our Yamhill community partners the SOC maximum benefit per application is $300.00. If your application request amount exceeds the funding limit please indicaticate on the application how the difference will be covered.

    Please be mindful of shipping or processing fees, include these in the total amount. Payments will be made directly to the vendor or service provider. Payments are made by credit card or check. Please note that checks are the payment of last resort and a completed W9 must be obtained from the vendor/service provider and submitted to Local Integration Family Specialist for processing. If a vendor/service provider fails to accept credit card payment or issue a completed W9, payment cannot be made.

    Clients must meet both of the following criteria:

    (1) Have children in the home or be working on reunification and needing funds to address items listed in their reunification plan. Children must be under 18.

    AND

    (2) Funds must be used to assist youth and their families with barriers listed below:

    • Housing Support
      • Rental assistance or temporary housing (e.g., rental payments, deposits, utility assistance)
      • Furniture, furniture delivery costs
      • Home modifications (e.g., ramps, handrails)
      • Pre-tenancy and tenancy support services (e.g., housing application, moving support, eviction prevention)
      • Housing focused navigation or case management
      • House cleaning services
      • Repairs related to damage by a youth in crisis
      • Utility Assistance (including broadband and cellular service)
    • Food assistance
      • Links to community-based food resources (e.g., application support to Supplemental Nutrition Assistance Program (SNAP/, Special Supplemental Nutrition Program for Women, Infants and Children (WIC)
      • Nutrition and cooking education
      • Fruit and vegetable prescriptions (for up to 6 months, also known as Veggie Rx) and healthy food boxes/meals
      • Medically-tailored meals
      • Food equipment and storage
    • Protection from climate events
      • Payment for devices that maintain healthy temperatures and clean air, including air conditioners, heaters, air filters, and generators to operate devices when power outages occur. NOTE: If you are a YCCO member you may qualify for this item as a benefit under HSRN assistance. Please reach out to the YCCO customer service line before applying for the SOC funds.
    • Therapeutic tools
      • Sand table
      • Sensory items
      • Weighted blanket
      • White noise machine
      • Noise canceling headphones
    • Item(s) that both relieve family stress and give opportunity for positive skills practice
      • Zoo or museum passes
      • Aquarium or pool passes
      • Internet and Technology support
    • Item(s) to support gender identity and sexual orientation
      • Gender appropriate clothes shopping
      • Haircuts and/or hair removal
    • Transportation assistance to appointments/activities
      • Bus pass or gas vouchers
      • Vehicle repair
      • Bike and bike repair
    • Non-Medicaid covered services
      • Art therapy
      • Respite
      • Equine therapy
      • Animal therapy expenses
      • Acupuncture, massage, or yoga

     

  • Is this family working towards reunification with their child?*

  • Referring agency/Provider contact information

  • Format: (000) 000-0000.

  • Parent/Guardian Demographic Information

    Information for family being referred to LIFT
  • Parent/Guardian 1 Date of Birth*
     / /
  • Parent/Guardian 1 Gender*

  • Parent/Guardian 1 Race and Ethnicity

    Select all that apply below.
  • American Indian or Alaska Native (Parent/Guardian 1)
  • Native Hawaiian or Pacific Islander (Parent/Guardian 1)
  • Middle Eastern / North African (Parent/Guardian 1)
  • Asian (Parent/Guardian 1)
  • Hispanic or Latino/a (Parent/Guardian 1)
  • Black or African American (Parent/Guardian 1)
  • White (Parent/Guardian 1)
  • Other Categories (Parent/Guardian 1)
  • Child(ren) lives with Parent/Guardian 1 what percentage of time:*

  • Parent/Guardian 1 Contact Information

  • Format: (000) 000-0000.
  • Is the family's physical address different than their mailing address?*
  • Primary Language(s) for Communication (Parent/Guardian 1)*
  • Is there another parent in the household?*

  • Parent/Guardian Demographic Information

    Information for family being referred to LIFT
  • Parent/Guardian 2 Date of Birth*
     / /
  • Parent/Guardian 2 Gender*

  • Parent/Guardian 2 Race and Ethnicity

    Select all that apply below.
  • American Indian or Alaska Native (Parent/Guardian 2)
  • Native Hawaiian or Pacific Islander (Parent/Guardian 2)
  • Middle Eastern / North African (Parent/Guardian 2)
  • Asian (Parent/Guardian 2)
  • Hispanic or Latino/a (Parent/Guardian 2)
  • Black or African American (Parent/Guardian 2)
  • White (Parent/Guardian 2)
  • Other Categories (Parent/Guardian 2)
  • Child(ren) lives with Parent/Guardian 2 what percentage of time:*

  • Parent/Guardian 2 Contact Information

  • Format: (000) 000-0000.
  • Is the address the same as Parent/Guardian 1?
  • Is Parent/Guardian 2's physical address different than their mailing address?
  • Primary Language(s) for Communication (Parent/Guardian 2)*

  • Child Demographic Information

  • Child 1 Date of Birth*
     - -
  • Child 1 Gender*

  • Child's Race and Ethnicity

    Select any below that apply.
  • American Indian or Alaska Native (Child 1)
  • Native Hawaiian or Pacific Islander (Child 1)
  • Middle Eastern / North African (Child 1)
  • Asian (Child 1)
  • Hispanic or Latino/a (Child 1)
  • Black or African American (Child 1)
  • White (Child 1)
  • Other Categories (Child 1)
  • Add another child?*
  • Child 2 Date of Birth*
     - -
  • Child 2 Gender*

  • Child's Race and Ethnicity

    Select any below that apply.
  • American Indian or Alaska Native (Child 2)
  • Native Hawaiian or Pacific Islander (Child 2)
  • Middle Eastern / North African (Child 2)
  • Asian (Child 2)
  • Hispanic or Latino/a (Child 2)
  • Black or African American (Child 2)
  • White (Child 2)
  • Other Categories (Child 2)
  • Add another child?*
  • Child 3 Date of Birth*
     - -
  • Child 3 Gender*

  • Child's Race and Ethnicity

    Select any below that apply.
  • American Indian or Alaska Native (Child 3)
  • Native Hawaiian or Pacific Islander (Child 3)
  • Middle Eastern / North African (Child 3)
  • Asian (Child 3)
  • Hispanic or Latino/a (Child 3)
  • Black or African American (Child 3)
  • White (Child 3)
  • Other Categories (Child 3)
  • Add another child?*
  • Child 4 Date of Birth*
     - -
  • Child 4 Gender*

  • Child's Race and Ethnicity

    Select any below that apply.
  • American Indian or Alaska Native (Child 4)
  • Native Hawaiian or Pacific Islander (Child 4)
  • Middle Eastern / North African (Child 4)
  • Asian (Child 4)
  • Hispanic or Latino/a (Child 4)
  • Black or African American (Child 4)
  • White (Child 4)
  • Other Categories (Child 4)
  • Add another child?*
  • Child 5 Date of Birth*
     - -
  • Child 5 Gender*

  • Child's Race and Ethnicity

    Select any below that apply.
  • American Indian or Alaska Native (Child 5)
  • Native Hawaiian or Pacific Islander (Child 5)
  • Middle Eastern / North African (Child 5)
  • Asian (Child 5)
  • Hispanic or Latino/a (Child 5)
  • Black or African American (Child 5)
  • White (Child 5)
  • Other Categories (Child 5)
  • Add another child?*
  • Child 6 Date of Birth*
     - -
  • Child 6 Gender*

  • Child's Race and Ethnicity

    Select any below that apply.
  • American Indian or Alaska Native (Child 6)
  • Native Hawaiian or Pacific Islander (Child 6)
  • Middle Eastern / North African (Child 6)
  • Asian (Child 6)
  • Hispanic or Latino/a (Child 6)
  • Black or African American (Child 6)
  • White (Child 6)
  • Other Categories (Child 6)

  • LIFT Request Information

  • Select the category/categories that your request fits into the best*
  • Which resources have you tried to access for assistance with this request?*
  • What other services/resources are the family ALREADY receiving?*
  • What experiences listed below are the family experiencing? (for tracking purposes only)*

  • FILE UPLOAD: PLEASE NOTE!

    ALL REQUESTS REQUIRE:

    • Documentation of quote, bill, and/or proof of rent balance for whatever LIFT is paying for.
    • W9 from whomever YCCO is paying that requires a CHECK. Find a blank W9 here.
    • The faster we receive these items, the faster we can move forward with the request process. If you are unable to upload documents at this time, please email them to mdobbins@yamhillcco.org after submitting your application as soon as possible.
    • For community partners applying for a food or gas card please click on the link to complete the Attestation Statement.
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  • Is the family interested in any being contacted about other Early Learning Hub programs such as Early Childhood Education, Home Visitation, or Parent Education?*
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