PIERCE COUNTY


Request for Assistance - Children in Dependency

KidConnect provides things and experiences that enhance and enrich the lives of children in dependency. This application form will be forwarded to us for our response. Be sure the information is accurate and all fields are completed. If your child needs it, ask us!

NOTE: KidConnect is a resource of last resort. Please identify all agencies and programs contacted in regards to this request.

THE CHILD
Full Name:   Age:    GENDER :    Male  Female
    Placement: Parent   Relative   Foster   Other    Specify (If Other):

REQUESTOR:  **(Required)

   Name: Phone:  EMail:

     Requestor Role:    Advocate   GAL   SW   Service Provider    Other,   Specify:


  SUPERVISOR
   Name: Phone:  EMail:


REQUEST
Type: Music/Arts   Sports   Graduation Needs   Camp   School Activity   Other,   Specify:


Please provide a detailed description of the request and the circumstances prompting it. For activities include the dates of the activity and the transportation plan if applicable. For goods explain how/why the vendor/provider was selected and state whether other vendors/providers are acceptable.


The Payment
Amount needed, including tax:      When is the item/ payment needed?
Payee's Name: Phone:
Payee's Address: Email:

Note: payment must be made directly to the business/provider. Payments cannot be made to foster parents or CAA/GALs.
We cannot reimburse for payments already made.


  Fill out these two fields ONLY if sending item directly to the recipient (Parent or Foster Parent)


  Recipient Phone: Email: