Kinship caregiver application

Please fill out the form below
1. Applicant Name (i.e., Kinship Caregiver Name)*

First NameLast Name
2. Applicant's Physical Address Street Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add Mailing Address, if Different than Physical Address.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Applicant's Date of Birth [Date of Birth] *

MonthDayYear
Date
4. Applicant's Phone Number *
Please enter a valid phone number.
5. Applicant's Email [example@example.com] *
example@example.com
6. Is Applicant a Veteran? *

YesNo
If yes, is Veteran receiving any other services? Please specify.
7. Is Applicant single or married?*

SingleMarried
If single, please provide Monthly Income [enter dollars]
If married, please provide joint Monthly Income [enter dollars]
8. Number of individuals in household [enter number]*
9. Are you the Legal Guardian for your kinship child(ren)?*

YesNo
10. Do you receive any services from the Children Youth and Families Department (CYDF)? This information will be kept confidential.*

YesNo
If yes, please describe [Enter Text]
11. Date kinship child(red) entered your care:*

MonthDayYear
Date
12. How long do you anticipate caring for your kinship child(ren)? *
13. Are you the primary caregiver for the kinship child(ren)*

YesNo
If no, who is? [enter text]
14. Do you consent to participate in the Kinship Caregiver program?

By consenting, you agree to receive case management services through a kinship navigator. These services are designed to help you identify and work towards your goals. Your kinship navigator will partner with you to identify your most urgent needs and help you set SMART goals (Specific, Measurable, Attainable, Relevant, and Time-bound).
Indicate consent*

YesNo
15. Do you consent to share information with service providers or partner agencies?*

YesNo
Attestation of Kinship Caregiver
I,First Name* Last Name* ,attest that I am the Kinship Caregiver the information I have provided to the Kinship Navigator Program is true and accurate to the best of my knowledge.
It is important to note that submitting an inquiry or applying for the Kinship Navigator program does not guarantee eligibility for services, nor that an award of financial assistance will be given. The program aims to assist kinship caregivers in finding and using a range of helpful programs and services, which may include financial aid, but receiving such aid is not guaranteed upon applying.

The undersigned hereby certifies that all information provided to establish eligibility for the program is true, accurate, and complete to the best of their knowledge and belief. I acknowledge that any attempt to provide inaccurate or untruthful documentation may disqualify me from receiving program services in the future.
Sign Here*

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Upload proof of Kinship

The following documents are required:

Copy of current driver’s license or state or federal photo ID for kinship caregiver
Upload Here

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Where did you hear about us? (select one)

Outreach EventFamily / FriendSocial MediaALTSD WebsiteOther
Upon clicking submit you will be shown a preview of your application.

You must click sign document to complete your submission.

A copy of your application will be sent to the email you have provided.
Should be Empty:

Please fill out the form below

Attestation of Kinship Caregiver