Date of Request (required)

Request Deadline (required)

Amount of Request (required) (put $1 for tutoring)

Child's Name (required)

Age (required)

Date of Birth

Person Requesting Funds (required)

Phone Number (required)

Cell Phone Number

Email Address (required)

DFS Caseworker's Name (required)

DFS Caseworker's Cell Phone Number (required)

DFS Caseworker's Email Address

Caregiver's Name (required)

Caregiver's Phone Number (required)

Caregiver's Cell Phone Number

Caregiver's Email Address

CASA's Name

CASA's Phone Number

CASA Cell Phone Number

CASA's Email Address

Funding Category (required)
---Education/Tuition/TutoringHealth/Vision/DentalTravelClothing and SuppliesLessons Sports/Dance/CampScholarshipsSchool Expenses, Trips etc.Miscellaneous

Please describe the child's situation and how the item will benefit them. Fax any supporting documentation to 222-3353 (required)

If the child is 15 or older have CHAFEE funds been requested? (required)
The child is under 15YesNo

If funding was denied who denied it?

Phone Number For Above Person

If approved make check payable to: (required)

Street Address To Send Check To (required)

City (required)

State (required)

Zip (required)