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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
Referrer First Name
*
Referrer 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
Youth First Name
*
Youth Last Name
*
Gender:
*
Male
Female
Transgender
Non-Binary/Other
Date of birth:
*
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
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
DCS Caseworker First Name
DCS Caseworker 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)