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FAM Application
Date
(mm/dd/yyyy)
Contact Information
Name
First Name
Last Name
Email
Verify Email
Birthday
(mm/dd/yyyy)
Gender?
Male
Female
Trans
Other
Physical Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Phone
Are you currently homeless?
Yes
No
What is your current living situation?
Do you have any children?
Yes
No
If YES, how many?
Are you employed?
Yes
No
If YES, where?
What is your monthly income?
Do you receive any of the following resources? (check all that apply)
Housing
Medicaid
Food Stamps
WID
LEAP
CCAP
CHAFEE
Are you currently in school?
Yes
No
Where?
What is your highest level of education completed?
Are you interested in attending college?
Yes
No
Would you like assistance navigating information regarding college?
Yes
No
What type of care were you in?
Foster Care
Kinship Care
How long were you in care for?
Did you age out?
Yes
No
What city and state were you in care?
Emergency Contact
First Name
Last Name
Emergency Contact Phone #
Relationship:
What are your top 3 goals right now?
Please describe your transportation situation.
What three words best describe you?
Who do you live with?
Describe your ethnic background?
select one
Hispanic
White
Black
Asian
Do you speak any languages other than English?
Yes
No
What activities are you involved in?
Are there any subjects in school or areas at work you are looking for help with?
Is there anything else you feel would be important for us to know about you?
What would you like to participate in?
FAM Time (Monthly get togethers with other foster alumni)
Mentoring (one on one)
Workshops (Information on suggested topics from foster alumni)