Hero to a Child Children's Needs Form

1

Applicant Name* This field is required.

First Name

Last Name

2

Applicant Email* This field is required.

example@example.com

3

Applicant Phone* This field is required.

Please enter a valid phone number.

5

How did you hear about Hero to a Child's children's needs program?* This field is required.

Case Manager or Licensing

Email

Facebook or Instagram

Guardian ad Litem Office

Foster Closer or Other Local Organization

Postcard or Mailer

Hero to a Child event or speaking engagement

Other

6

Does the child have a Guardian ad Litem?* This field is required.

Yes

No

Unknown

7

How long have you been advocating for this child?

8

Case Number* This field is required.This can be found in Optima

9

Shelter Date

Date

10

Case Management Organization* This field is required.

Family Support Services

Youth and Family Alternatives

Lutheran Family Services

Other

11

In which county did the case originate* This field is required.

Pasco

Pinellas

Other

12

If other, please list originating county and case management organization* This field is required.

13

Child First Name* This field is required.

14

Child Last Name or Initial* This field is required.

15

Your Birthdate* This field is required.

Date

16

Your Gender* This field is required.

Female

Male

Nonbinary

Transgender

17

Child Birthdate* This field is required.

Date

18

Child Gender* This field is required.

Female

Male

Nonbinary

Transgender

19

Child Race/Ethnicity* This field is required.Select All that Apply

American Indian or Alaska Native

Asian

Biracial Multi-Racial

Black African American

Latino Hispanic Non-White

Native Hawaiian or Pacific Islander

Latino Hispanic White

White

20

Your Race/Ethnicity* This field is required.Select All that Apply

American Indian or Alaska Native

Asian

Biracial Multi-Racial

Black African American

Latino Hispanic Non-White

Native Hawaiian or Pacific Islander

Latino Hispanic White

White

21

Tell us a little about the child* This field is required.Please share a little about the child's favorites (color, hobby, activities), their grade in school, etc. This information helps us tell the stories of our kids in care and involve additional donors. All stories are anonymized.

22

Tell us a little about yourself* This field is required.Please share a little about the your favorites (color, hobby, activities). This information helps us tell the stories of our kids in care and involve additional donors. All stories are anonymized.

23

County Child Resides In* This field is required.

Pasco

Pinellas

Hillsborough

Other

24

County You Reside In* This field is required.

Pasco

Pinellas

Hillsborough

Other

25

Zip of Child Placement* This field is required.

26

Zip of Your Placement* This field is required.

28

Group Home Name

29

Placement Stability - How confident are you in the stability of this placement?* This field is required.

Very Confident

Confident

Somewhat Confident

Not at All Confident

Unsure

30

Placement History* This field is required.Please tell us about the child, their placement, and their placement history. This helps us to understand the child's history and how the met need will help them for the future.

31

Have the caregivers achieved or started the Level 1 license process?

Yes, they are a licensed Level 1 home

Yes, they have started the licensing process

No, they do not have the means to achieve Level 1 licensing

No, they are not licensed in becoming Level 1 licensed

I do not know

32

Does the child have siblings in care?

No

Yes, and they live together

Yes, but they do not live together

33

Do you have any siblings in care?

No

Yes, and they live together

Yes, but they do not live together

34

What are the names and ages of siblings in care?Name, Age

35

Guardian ad Litem First Name

36

Guardian ad Litem Last Name

37

Guardian ad Litem Email

example@example.com

38

Guardian ad Litem Phone

Please enter a valid phone number.

39

Please select the request category that best fits the need you are requesting:

Birthday - party or gift

Education - tutoring, school supplies, scholarship, other school-related expense

Emergency/Basic - food, clothes, beds, personal care, medical

Caregiver - items to help maintain placement stability

Social/Emotional - sibling visits, extracurriculars, bikes

Aged Out/Aging Out youth - apartment kits, post secondary education support

Therapeutic - therapy, diagnostic testing, second opinions on meds

40

Birthday Need Type* This field is required.Birthday gift: $50 cap; Birthday outing: $100 cap

42

Emergency/Basic Need Type* This field is required.

Clothing/Shoes

Bed/Bedding (frame, mattress, crib, pillows)

Personal Care Items

Baby Items (stroller, car seat, diapers, wipes, etc.)

Emergency Need

Food Assistance

Medical (not covered by Medicaid - glasses, dental)

Other

43

Caregiver/Reunification Need Type* This field is required.Funding support to provide placement stability or reunification with relative, non-relative, or biological parent(s).

Emergency Expense

Food Assistance

Home Study Needs

Level 1 License Assistance

Other

44

Social/Emotional (extracurriculars) Need Type* This field is required.Max funding availability is $500 per child per year.

Bike

Club or Activity Fees

Extracurricular Activity

School Field Trip

School Special Event (prom, homecoming, grad bash, etc.)

Summer Camp

Other (toys, games, art supplies, etc.)

45

Aged Out/Aging Out Youth Need Type* This field is required.

First Apartment Supply Kit

Graduation Fees

Post Secondary Education Support

Technology

Teen Parent Assistance (diapers, wipes, crib, etc.)

Teen Supply Bag

Other

46

Therapeutic Services Need Type* This field is required.

Behavioral Health Therapy

Mental Health Therapy

Diagnostic Testing

Occupational Health Therapy

Other

47

What is the level of need?* This field is required.

Significant need for help

Caregiver(s) doing ok but could use some help

I would like to provide this to the child regardless of need

Request prompted by caregiver

I do not know

48

How many children will this request support? * This field is required.

49

What school does the child attend?

50

What grade is the child in or entering?* This field is required.

51

Describe the need* This field is required.Please describe the need including reason for need and how the child will benefit from assistance.

52

Caregiver First Name* This field is required.

53

Caregiver Last Name* This field is required.

54

Caregiver Email* This field is required.

example@example.com

55

Caregiver Phone* This field is required.

Please enter a valid phone number.

56

Vendor or Provider Name* This field is required.Please provide name of company, location, provider, tutor, etc.

57

Does the child have reliable transportation to attend sessions?* This field is required.

Yes

No

I don't know

58

Is this request for continuation of prior funding?* This field is required.

Yes

No

59

How many of the previous sessions did the child attend?

60

Link(s) to requested item(s)If there is a specific item the child has expressed wanting or needing, please provide link(s). We will do our best to purchase the item if it falls within our cost parameters.

61

Estimated Cost of Request* This field is required.

62

How will this request be paid?

Check sent to vendor

Credit Card online or by phone to vendor

Reimbursement - prior approval required

Unknown/Office to decide

63

If reimbursement, who will the check be paid to?* This field is required.

64

How will items by received?If you have received specific items to be purchased, please let us know how/where you would like to receive them.

Pick up at Hero to a Child office (4500 140th Ave N, #118, Clearwater)

Ship to me

Ship to other

65

Recipient First Name* This field is required.

66

Recipient Last Name* This field is required.

67

Shipping Phone

Please enter a valid phone number.

68

Shipping Address* This field is required.

69

Shipping City* This field is required.

70

Shipping State* This field is required.

71

Shipping Zip Code* This field is required.

72

Is this address safe to accept deliveries even if no one is home?* This field is required.

Yes

No

I don't know

73

Date request is needed by

Date

74

If applicable, please attach invoice or receiptMust be .pdf, .doc, or.docx) Only one attachment will be accepted. Please condense receipts to one PDF.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB