“By completing this application, the participant is hereby providing EmpowerMEnt an initiative of the Multi-Agency Alliance for Children (MAAC) authorization to maintain and share their information in a confidential manner. Pertinent information may be shared with EmpowerMEnt staff, agency, partner(s), and others for applicable reasons.”

* 1. Today’s Date:

* 2. Origin of Application:

* 3. Applicant Information

* 4. Contact Information

* 5. Preferred methods of communication: (please check all that apply)

* 6. Status:

* 7. Are you alumni of foster care?

* 8. Were you in foster care in Georgia?

* 9. If No, what state?

* 10. Were you in foster care:

* 11. Foster Parent or Agency Information

* 12. Placement experience: (please check all placement types where you have lived)

* 13. Type of Current School Enrollment/Status (Check one)

* 14. Type of Current School Enrollment/Status

* 15. Enrollment Location (Check one)

* 16. Enrollment Type (Check one)

* 17. Does the student have an IEP?

* 18. Date last updated

* 19. Class Type (Check all that apply)

* 20. School Information

* 21. Are you employed?

* 22. If yes,

* 23. Where?

* 24. Are you participating in an Internship?

* 25. Who (if needed) will support you?

* 26. Emergency Contact (besides DFCS/ILP/Agencies)

* 27. Marital or Commitment Status:

* 28. Do you have children?

* 29. Additional Child Information

* 30. Minority Groups (Check all that apply)

* 31. Individualized Development Account (IDA)

  Yes No
Do you know about IDA?
Do you have an IDA account?
If so, have you matched out?

* 32. Matched out for:

* 33. Have you completed any financial education?

* 34. If yes, your assessed goal is related to: (select all that apply)

* 35. Do you have health insurance?

* 36. If yes, who is the provider?

* 37. Permanency Plan (what is your permanency plan)

* 38. I have a:

* 39. EmpowerMEnt Priorities (what area(s) are you interested in?) Check all that apply

* 40. What are your strengths, talents, and gifts that make you unique?

* 41. What do you need support or help with to be successful in transitioning out of foster care and reaching your goals?

* 42. Please describe why you would join EmpowerMEnt?

* 43. Communication is important and we want to know what forms of communication you have.

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