Caseworker/Agency Details: Date * Caseworker name entering the information * First Last Caseworker who will bring the youth to shop (if applicable) First Last Placing Agency or County Name * Agency or County Contact's Phone Number * Agency or County Contact's Email * Youth Information: Child 1 Name: * First Last Child 1 Gender * Child 1 Age * Child 1 Birthdate * Child 1 Ethnicity * — Select — American Indian Asian Black or African American Hispanic or Latino Native Hawaiian White Unsure County from which child 1 is from * Child 2 Name First Last Child 2 Gender Child 2 Age Child 2 Birthdate Child 2 Ethnicity — Select — American Indian Asian Black or African American Hispanic or Latino Native Hawaiian White Unsure County from which Child 2 is from Child 3 Name First Last Child 3 Gender Child 3 Age Child 3 Birthdate Child 3 Ethnicity — Select — American Indian Asian Black or African American Hispanic or Latino Native Hawaiian White Unsure County from which Child 3 is from Child 4 Name First Last Child 4 Gender Child 4 Age Child 4 Birthdate Child 4 Ethnicity — Select — American Indian Asian Black or African American Hispanic or Latino Native Hawaiian White Unsure County from which Child 4 is from Is child in foster care: Please Choose One Yes No Youth Living Arrangements: Where is the youth residing: (Resource Family, Shelter, Group home, etc.) * If Resource Family, please provide the following information: Family Name First Last Family Phone Number Family Email Address Family Mailing Address Address Line 1 City State Zip Code Is This a Kinship Foster Care Placement Please Choose One Yes No If Group Home, please provide the following information: Group Home Name Phone Number Group Home Address Address Line 1 City State Zip Code If Shelter, please provide the following information: Shelter Name Phone Number Shelter Address Address Line 1 City State Zip Code Document Upload: Please upload your Agency Placement Paperwork documents: Select File(s)
