Milton Foster Children's Fund Application - CASA of the Pikes Peak Region

Youth Information

Youth's Name:

Youth's Race:

Youth's Age

To be considered for funding, youth must be both:

In out-of-home placement and not living with biological parents AND
Has an open child abuse/Dependency and Neglect case through El Paso or Teller County

Approximate length of time in out-of-home placement:

Name of person making request:

Relationship to youth:

Requester's phone number:

Requester's Email:

Does the youth have a CASA? If yes, what is the CASA's name? (Having a CASA is not required to request funding.)

Name of foster family or group home:

Foster family or group home address (If approved, funding will be mailed to this address)

Street Address Address Line 2 City State ZIP Code

Foster family or group home phone number:

Foster family or group home email:

Youth’s Caseworker:

Caseworker's Email:

Name of agency & phone number:

Funding Request Information

Amount of request ($):

Has this youth applied for and/or received funds from MFCF previously?

If yes, what is the approx. date of funds received and details of the request?

Please give a description of the item(s) / services being requested:

What funding resources have you already investigated, and the results?

Are you requesting full funding or will another agency/individual be sharing the cost? Please give details:

Name of vendor providing the service as it should appear on the check. (Checks cannot be made out to individuals and will be made payable to the vendor providing the service.)

Special Mailing instructions. (Checks will be mailed to the foster family/group home.)

Agreement:

Yes, I agree

My agreement acknowledges that: 1. I have read and understand the MFCF Guidelines and Responsibilities sheet. 2. I will ensure a receipt for goods/services purchased is provided to the MFCF committee. 3. I will ensure any unused funds will be returned to the MFCF committee within 30 days of receipt. 4. I will ensure the child to send a Thank You note that can be used anonymously for grant writing and reporting purposes. This will allow us to assist more children in the future! 5. Funds will be used only for the purpose stated in this application.

Today's Date:

Milton Foster Children’s Fund Application

MFCF form

Youth Information

Funding Request Information

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