Milton Foster Children's Fund Application for Funding - CASA of the ...

APPLICATIONChild’s Name: __________________________ Race: __________________Name of person making this request: __________________________________________Today’s Date: _________________Relationship to Child: __________Requestor’s Phone Number and Email: _______________________________________________________________Child’s age: ________________________Approximate length of time in out-of-home placement: ____________Name of Foster Family or Group Home: ______________________________________________________________Foster Family or Group Home Address: ______________________________________________________________________________________________________________ Phone Number: __________________________________Child’s Caseworker: _________________________________ Email address: _______________________________Agency and phone number: ________________________________________________________________________Amount of request ($): ___________________Has this child applied for and/or received funds from MFCF previously? (circle one) Yes NoIf yes, details: ___________________________________________________________________________________Please give a description of the item(s) / services being requested: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What funding resources have you already investigated, and the results:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you asking for full funding of this request or will we be participating in the funding with another agency orindividual? Please give details: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please note:• Checks will be mailed to the caregiver. A copy of the award letter will be mailed to the personwho is making the request.• Requestor will be responsible for ensuring all funds are used only for the purpose stated in thisapplication and that the MFCF committee will receive a receipt for that purchase.• Checks cannot be made out to individuals and will only be made payable to the vendor who isproviding the service.