Request Form | 18-26 | Foster Angels of Central Texas

Request Form | 18-26

"*" indicates required fields

Who is filling out this request?*

Case ID*

Your Age*

CASA Name*

First Last

CASA Email*

CASA Supervisor’s Name*

First Last

CASA Supervisor’s Email*

Case Manager Name*

First Last

Case Manager Email*

Caseworker Name*

First Last

Caseworker Email*

Foster Parent Name*

First Last

Foster Parent Email*

Who are you licensed through?*

Nurse / Physician Name*

First Last

Nurse / Physician Email*

Your Name*

First Last

Your Email*

Attorney Name*

First Last

Attorney Email*

Your Name*

First Last

Your Preferred Pronouns*

Your Email*

Your Name*

First Last

Your Email*

Your Phone Number*

Your Supervisor's Name*

First Last

Your Supervisor's Email*

What is your relation to the youth you are requesting for?*

How did you find out about Foster Angels?*

Is this youth in extended foster care?*

Yes

CPS Caseworker Name*

First Last

CPS Caseworker Email*

Who is your most recent caseworker with CPS?*

First Last

Caseworker Phone #*

Date of Birth*

Do you have a PAL worker?*

Yes

Does this youth have a PAL worker?*

Yes

PAL Worker's Name*

First Last

PAL Worker's email*

Does this youth have a CASA worker?*

Yes

CASA Worker's Name*

First Last

CASA Worker's Email*

Name of Your School*

Name of your Facility*

# of youth you are requesting for*

Placement Zip Code*

Youth 1

First and Last names of each youth you are requesting for*

First Last

Youth's Age*

Youth's Preferred Pronouns*

Youth's Race/Ethnicity (Check all that apply)*

Black/African American

White/Caucasian

Native American/Indigenous

Hispanic/Latino

Asian/Pacific Islander

Prefer not to answer

Your Race/Ethnicity (Check all that apply)*

Caucasian

African American

Native American

Asian

Hispanic

Prefer not to answer

Youth 2

First and Last names of each youth you are requesting for*

First Last

Youth's Age*

Youth's Preferred Pronouns*

Youth's Race/Ethnicity (Check all that apply)*

Black/African American

White/Caucasian

Native American/Indigenous

Hispanic/Latino

Asian/Pacific Islander

Prefer not to answer

Youth 3

First and Last names of each youth you are requesting for*

First Last

Youth's Age*

Youth's Preferred Pronouns*

Youth's Race/Ethnicity (Check all that apply)*

Black/African American

White/Caucasian

Native American/Indigenous

Hispanic/Latino

Asian/Pacific Islander

Prefer not to answer

Youth 4

First and Last names of each youth you are requesting for*

First Last

Youth's Age*

Youth's Preferred Pronouns*

Youth's Race/Ethnicity (Check all that apply)*

Black/African American

White/Caucasian

Native American/Indigenous

Hispanic/Latino

Asian/Pacific Islander

Prefer not to answer

Youth 5

First and Last names of each youth you are requesting for*

First Last

Youth's Age*

Youth's Preferred Pronouns*

Youth's Race/Ethnicity (Check all that apply)*

Black/African American

White/Caucasian

Native American/Indigenous

Hispanic/Latino

Asian/Pacific Islander

Prefer not to answer

Youth 6

First and Last names of each youth you are requesting for*

First Last

Youth's Age*

Youth's Preferred Pronouns*

Youth's Race/Ethnicity (Check all that apply)*

Black/African American

White/Caucasian

Native American/Indigenous

Hispanic/Latino

Asian/Pacific Islander

Prefer not to answer

Youth 7

First and Last names of each youth you are requesting for*

First Last

Youth's Age*

Youth's Preferred Pronouns*

Youth's Race/Ethnicity (Check all that apply)*

Black/African American

White/Caucasian

Native American/Indigenous

Hispanic/Latino

Asian/Pacific Islander

Prefer not to answer

Youth 8

First and Last names of each youth you are requesting for*

First Last

Youth's Age*

Youth's Preferred Pronouns*

Youth's Race/Ethnicity (Check all that apply)*

Black/African American

White/Caucasian

Native American/Indigenous

Hispanic/Latino

Asian/Pacific Islander

Prefer not to answer

Youth 9

First and Last names of each youth you are requesting for*

First Last

Youth's Age*

Youth's Preferred Pronouns*

Youth's Race/Ethnicity (Check all that apply)*

Black/African American

White/Caucasian

Native American/Indigenous

Hispanic/Latino

Asian/Pacific Islander

Prefer not to answer

Youth 10

First and Last names of each youth you are requesting for*

First Last

Youth's Age*

Youth's Preferred Pronouns*

Youth's Race/Ethnicity (Check all that apply)*

Black/African American

White/Caucasian

Native American/Indigenous

Hispanic/Latino

Asian/Pacific Islander

Prefer not to answer

Current Placement County*

If other, please specify county & region.*

County where the legal case is open. If not in extended foster care, select N/A*

If other, please specify county & region.*

Type of Placement*

If other, please specify*

Stages of Care*

If other, please specify*

What kind of placement are you living in?*

Are you in a higher education or training program?

If other, please specify*

What do you need and why?*

In order to fill this need, what would be your preferred assistance?

gift card

direct order of items

other

If other, please indicate.

If gift card, please give your preferred store/vendor.

If direct order of items, please list them here with links.

Have you received assistance from Foster Angels before?*

Yes

If Yes, describe your past interactions with Foster Angels as specifically as possible.*

Is youth currently in, or graduated from, any of the following education programs?*

Give the background of the case in 3-5 sentences. Describe what is needed and why.*

Is this court ordered?*

Yes

Which judge court ordered this and on what date?*

Has this youth received Foster Angels assistance during the last calendar year?*

Yes

(This does NOT disqualify the request for approval)

If Yes, what is the previous request number?*

Are you requesting assistance in the form of a gift card, check, or specific items? (Please note: we do not write reimbursement checks)*

gift card

check

direct order of items

Please enter the store you would like the gift card to and the amount*

Please enter where the check should be written out to and the amount. (Please confirm business names and amounts!)*

Please list items that you would like directly ordered for assistance. (Please include links if available!)*

Would you like this request shipped to the client if we are able?*

Yes

Client Shipping Name*

First Last

Client Shipping Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number for Shipping*

Anything else you would like to say about this request?*