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: