"I Can Do It Fund" Application

1
The Laura B. Smith Fund was created to support teens aging out of care and perusing post-secondary education. These funds will provide for items, services and needs beyond the scope of our traditional request process. If you have any questions about which form you should fill out, please reach out to iamforthechild@herotoachild.org
I don't understand
I understand
2
Applicant Full Name* This field is required.
First Name
Last Name
3
Email Address* This field is required.
example@example.com
4
Cell Phone Number* This field is required.
Please enter a valid phone number.
5
In which county did this child's case originate?* This field is required.We support children whose cases originated in Pinellas and Pasco Counties but in some circumstances we will also support children from other circuits who are living in Pinellas and Pasco County and being visited by a Circuit GAL. Visiting GALs should first request assistance from the originating circuit for any non-emergency needs (i.e. normalcy, tutoring, beds, etc.). If assistance is not available from the originating circuit GALF will consider on a case by case basis and based on available resources. For emergency needs such as clothing, GALF will provide gift cards for any child seen by one of our GAL volunteers or staff.
Pasco County
Pinellas County
Other
6
What is your role?* This field is required.
Guardian ad Litem
Child Advocacy Manager
Case Manager
Other
7
Young Adult Full Name* This field is required.
First Name
Last Name
8
City and County Child Resides In (i.e. Gulfport, Pinellas)
9
Zip Code of Child's Placement* This field is required.
10
Age/Grade* This field is required.
Grade 11
Grade 12
GED
Post-secondary education
Other
11
What is their GPA?* This field is required.
12
Race/Ethnicity* This field is required.
Asian/Pacific Islander
Biracial/Multi-Racial
Black/African American
Latino/Hispanic Non-White
Latino/ Hispanic White
Native American
White
Other
13
Placement stability: How confident are you in the stability of this placement? 1= Not Confident, 5 = Very Confident
1
2
3
4
5
Not Confident
Very Confident
14
How long has he/she been in this current placement?
Night to night placement
Lives on own
Less than 30 days
Less than 3 months
3-6 Months
6-12 Months
12-24 Months
2-3 Years
3-5 Years
Longer than 5 Years
15
How long have you been advocating for this young adult?
Less than a year
1-2 years
3-5 years
Longer than 5 years
This young adult has aged out of the GAL Program
16
How many placements has the young adult had?
1-4
5-9
10+
17
Tell us about this young adult's placement history and where they live now.
Huge
Large
Normal
Small
Ok
Ok
18
Type of Placement* This field is required.
Foster Home
Relative Caregiver
Non-Relative Caregiver
Group Home
In Home or Reunified
Extended Foster Care
Youth Aged Out - lives on own
Other
19
Date Request Needed ByOur preferred payment method is credit/debit card. Please note checks are only cut on the 1st and the 15th. Requests over $500 require additional approval and will delay processing
Date
Year
Month
Day
20
Type of Assistance Needed* This field is required.
Technology Needs (laptop, tablets, calculators, programs/applications, internet access, etc.)
Transportation Needs
Direct Course Funds - certificate programs, uniforms, tools, specialty equipment, etc.
Child care assistance to complete post-secondary education/GED classes
Aging Out Assistance
21
Estimate of how much does this item cost?* This field is required.
22
Please describe the young adult’s need. Be specific and include information on how the child will benefit from the assistance. * This field is required.If needed, please include the exact items, sizes and colors needed so that we can make sure that the appropriate items are purchased and sent to the child.
Huge
Large
Normal
Small
Ok
Ok
23
What are this young adults goals/plans for the future and how will fulfilling this request help to get them there? * This field is required.
Huge
Large
Normal
Small
Ok
Ok
24
Will this request be paid with a credit card?* This field is required.Most vendors will accept credit card, but some will not. If you are uncertain, please call and confirm with the vendor prior to applying so that you know how we should pay for this request. If this is an item from office stock, check no.
YESNO
25
Does this child have a trust fund or receive SSI or SSDI?
YESNO
26
Shipping Information: If this is a request for an item that will be shipped from a vendor (ie. a computer), please provide shipping information and include name, address, zip code and telephone number. If not applicable type N/A.Don't forget to tell us WHO it should be shipped to.
Huge
Large
Normal
Small
Ok
Ok
27
Please provide who payment will be paid to, amount of payment and address of vendor/payee if applicable. If this is to be paid online, please include web address.* This field is required.Please note, if we find the product for less expense elsewhere, we will purchase it at that location.
Huge
Large
Normal
Small
Ok
Ok
28
Please provide any additional case information that will help us in approving this request or securing funding. If none, type N/A. * This field is required.This is your last chance to get to a yes! If there are extenuating circumstances, the request is a little odd, a large expensive, or something else entirely, let us know why we should approve your request.
Huge
Large
Normal
Small
Ok
Ok
29
If Applicable, please attach invoice.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
30
If Applicable, please attach receipt.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
Should be Empty: