HEARTY Support Form
This form is used to both submit HEARTY requests and to record distribution of Walmart Gift Cards. Only DJJ or AFOI staff may submit requests. Contact Karen Beiber at karen.beiber@afoi.org if you have questions or need assistance.
Date
*
-
Month
-
Day
Year
Date
Your Name
*
Please Select
Atwell, Andrea
Banks, Sharonda
Callis, Rowena
Davis, Jarrod
Peoples, George
Smith, Melissa
AFOI staff
Email
*
example@example.com
JTS Number of youth you are referring
*
Youth Race
*
Please Select
African American
Asian American
Caucasian
Native American
Multi-Racial
Other
Hispanic
*
Please Select
Hispanic
Non Hispanic
Youth Gender
*
Please Select
Female
Male
Transgender
Nonbinary
Other
Youth Age
*
Please Select
14
15
16
17
18
19
20
21
Type of Support
*
Please Select
Bed for reentry to family home
Clothing/equipment for employment (e.g. work boots, pants, shoes, tools)
DMV ID/License/ Birth Certificate
Education/training needs (e.g. forklift certification, driving course, GED)
Healthcare needs not covered by insurance/lack of insurance
Laptop for education/work purposes
Tattoo Removal
Transportation (short term) for employment, mandatory programs, mental/physical health care needs
Walmart $100 gift card given
Description of Request (as needed)
Previous Request for this youth (date, amount, type of requests submitted)
*
Save
Submit
Should be Empty: