YOUTH REFERRAL FORM

Are you in foster care and wondering how to plan for your future? Do you know a youth in foster care who would make an ideal candidate for the Keys to Success program? Fill out the information below to make your referral. If you have any questions, please email the Keys to Success program director, Diane Daily at ddaily@affcf.org. Thank you!

1. REFERRING PERSON INFORMATION

First Name *

Last Name *

Phone Number *

Email Address *

Relationship to youth *

Why are you referring the youth to the Keys to Success program?

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2. YOUTH INFORMATION

First Name *

Last Name *

Gender: *

Male

Female

Street Address *

Date of birth: *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address

Was this youth in the Arizona foster care system and adopted or placed in legal guardianship at age 16 or later? *

Yes

No

Was this youth in the Arizona foster care system and reunified with their biological parent(s) at age 14 or later? *

Yes

No

Youth's Current Educational Status: *

Enrolled in high school or below

High school graduate

GED recipient

Left high school without graduating

Current grade level if in high school or below: *

Is youth currently employed? *

Yes

No

Do you have or have access to his or her vital documents (i.e. birth certificate)? *

Yes

No

Employment can sometimes be affected by criminal convictions. For that reason, has youth ever been convicted of a crime, on probation or parole or have any charges pending against him/her? *

Yes

No

If yes, please list offense and approximate date:

YOUTH'S DCS CASEWORKER INFORMATION

First Name

Last Name

Phone Number

Email Address

YOUTH'S GAL CONTACT INFORMATION

First Name

Last Name

Phone Number

Email Address

3. CAREGIVER INFORMATION

First Name

Last Name

Phone Number

Email Address

Caregiver relationship:

Caseworker	Foster parent
CASA	Group home staff
Kinship caregiver	Youth in foster care
Other (please explain) Other (please explain)