Child Information

Last Name:    First Name:    
Also Known as:    Date of Birth:    
Grade in School:              Gender:    Male        Female
Ethnicity:    African-American         Asian-American           Caucasian           Hispanic
           Native American         Multi-Ethnic            Other:  
Placement:    Relative         Foster           Group Care  
Legal Status:    Legally free         Dependent           Guardianship  

Referral Source

Caregiver Name:    Home Phone:   Work Phone: 
Address:   
May Capital Kids Connection Contact You?:    Yes        No  
Email Address:   

Request Information

Request Information: Check the relevant category below for the requested item or service
    Funding for activity: class, camp, etc. needed equipment; miscellaneous request
    Funding for tangible item: clothing, toys, bike, graduation pictures, etc.
Describe the request:   
Services/Goods Provider Name:         Phone:   
Address of Provider:   
If the item needs to be picked up, who will do that?   
Exact amount of item plus tax:   
If there is a deadline date for this request, when is it?   

Please read and check box:    I understand that incomplete requests cannot be processed. CKC does not reimburse without prior authorization. I authorize CKC to provide this service. No state funding or resources are available to fund this request.

Date of request:        DCFS Case Number:   
Social Worker/Case Manager:   
Email Address:        Phone Number:
Office:      DCFS Olympia         DCFS Shelton         Other: