2026 Reimbursement Form

2026 Reimbursement Request

Kinship Families Only

Use this form only for CPR/First Aid reimbursements and Dog Rabies Vaccine or Dog License reimbursements.
At this time, BOOST a FOSTER FAMILY only accepts referrals for not-yet-licensed KINSHIP families experiencing financial hardship or who have other barriers prohibiting them from becoming licensed or taking placement.

If you are the family filling out this form STOP RIGHT HERE and have your DCS or Agency Worker complete the form. If the family fills out this application, assistance will be denied.

PLEASE NOTE: Boost a Foster Family will reimburse eligible families after they have acquired the service (CPR/1st Aid class or dog rabies vaccine/license). Boost will only reimburse actual costs up to the following limits:
- CPR/1st Aid - $65/person
- Dog Rabies Vaccine (no other vaccines) - $42/dog
- Dog License (tag not included) - $65/dog
Itemized receipts must be uploaded in this form to receive reimbursement.

INSTRUCTIONS:

1. Family obtains service at a provider of their choice. (see recommendations to make sure provider/service meets all requirements)

2. Family submits to you a copy of their itemized receipt.

3. DCS/Agency Worker completes this form and uploads receipts. Receipts older than 60 days will NOT be reimbursed.

4. Boost a Foster Family mails a check to the family directly which may take up to two weeks to process.
INITIAL HERE to agree that you have communicated to the family the reimbursement limits and 2 weeks processing time. .
Family Information

Please provide the following data on the family in need of assistance (all entries are required):
YESNO
General Assistance Request Form (safety items, physicals, well water tests, etc)Pool Fence Request FormHousehold Repairs Form
Family Primary Contact*

First NameLast Name
Family Primary Contact Email (best email for the family)
example@example.com
Family Primary Contact Phone Number*

Area CodePhone Number
Family MAILING Address - where we will send a reimbursement check.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence*
Additional Required Information
Nature of Kinship Relationship*
What best describes the family's situation?*
YesNo

List ALL Adults in the Home including adult children (more than 5 adults, please list data in Additional Info)*

Rows	Race/Ethnicity
Adult 1
Adult 2
Adult 3
Adult 4
Adult 5

Number of Adults over 60 living in the home*
Number of Veterans in Home*
Total Number of Children in Home*
Birth children, adoptive children, foster children and informal placements
Number of Foster Children in Home*
only foster children

List ALL Children under 18 in the Home include those ALREADY PLACED and those AWAITING PLACEMENT. (more than 8 children, please list data in Additional Info)*

Rows	Race/Ethnicity	Relationship	Age	Gender
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7
Child 8

Agency Information
I certify that I work for DCS, the Care Portal, CASA, a foster care licensing agency or other nonprofit agency in Arizona and that I am filling this out on the behalf of an Arizona family in need.

Boost counts on workers like you to determine which families truly need financial help. Because we care so much for families, we want to offer this to every family, but Boost will be able to help more needy families if you rule out families that can afford these services on their own. Help us by requesting for the families who truly need this assistance.
Select Agency*
If not listed above, please type Agency Name and full address.
Referring Worker Name*

First NameLast Name
What best describes my organization?
Referring Worker E-mail*
Referring Worker Cell Phone Number*

Area CodePhone Number
VerbalEmailSigned Release of Information FormOther
Reimbursement Information

CPR - $65/person | Dog Rabies Vaccine - $42/dog | Dog License - $65/dog
CPR/First Aid ClassesDog Rabies VaccinationsDog License
CPR/First Aid Class

Maximum reimbursement $65/person.

Boost will only reimburse for cost of Child/Infant/Adult-AED CPR & 1st Aid classes that are required for licensure by OLR.
Number of Adults who received CPR/First Aid Classes *
UPLOAD CPR/1st Aid Receipt*

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Rabies Vaccinations

Maximum reimbursement $42/dog

Boost will only reimburse for dog rabies vaccine. No other vaccines will be reimbursed. If the family opts for more vaccines, Boost will only reimburse the cost of the rabies portion.
Number of dogs received rabies vaccines*
UPLOAD Vaccination Receipt*

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Dog Licenses

Maximum reimbursement $65/dog
Number of dogs who received licenses*
UPLOAD Dog License Receipt(s)*

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Please include any other information, you think pertinent.
Please note: We commit to responding to this referral as soon as possible. Sometimes additional information is required in order to fulfill the order. If we do not receive the requested information within 90 days, this referral will expire.
Signing your name here confirms your acceptance of Boost a Foster Family Terms and Conditions and that you have received permission from the family to share their information.*
Enter the message as it's shown*
You will receive an email confimation after clicking SUBMIT. If you do not receive the email within a few minuntes, please check this page to make sure all the required fields have been completed. Contact us if you have futher problems.
Should be Empty:

Family Information

Additional Required Information

Agency Information

Reimbursement Information