Tutoring and Special Needs

Foster or Emancipated Name

Date of Birth

For Grant Reporting Purposes: Applicant Race

Ethnicity

Placement Agency

Address

Street Address City State ZIP Code

Foster Parent/Guardian First Name

Foster Parent/Guardian Last Name

Email(Required)

Cell Phone

Describes the purpose for financial assistance:

Tutoring

Special Needs

Food / Clothing

Electronics

Academic / Scholarship

Other

Comments / Other - Explanation

Is this an emergency need?

Yes

No

If no, please allow up to 3 weeks for processing

Total cost of need $

Amount of assistance requested $

Date fee is due

Is this a one time fee?

Yes

No

If no, please explain

If no, explain

For a continual payment request, list start date and end date

*Applicant must re-apply every 3 months. Allow 3 weeks for new application processing*

To what organization / service provider will the funds be paid? (If unknown, provide asap)

Organization phone

Organization Address

Street Address City State ZIP Code

Have you applied for, or are you receiving aid for this same purpose from elsewhere?

Yes

No

If Yes. Source Name

Source Phone

Contact Name

Contact Email

* Documentation of foster placement, adoption or emancipation required with application

Signature