“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.”

Today’s Date:

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* 1. Today’s Date:

Origin of Application:

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* 2. Origin of Application:

Applicant Information

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* 3. Applicant Information

Contact Information

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* 4. Contact Information

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

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

Status:

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* 6. Status:

Are you alumni of foster care?

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* 7. Are you alumni of foster care?

Were you in foster care in Georgia?

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* 8. Were you in foster care in Georgia?

If No, what state?

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* 9. If No, what state?

Were you in foster care:

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* 10. Were you in foster care:

Foster Parent or Agency Information

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* 11. Foster Parent or Agency Information

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

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

Type of Current School Enrollment/Status (Check one)

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

Type of Current School Enrollment/Status

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* 14. Type of Current School Enrollment/Status

Enrollment Location (Check one)

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* 15. Enrollment Location (Check one)

Enrollment Type (Check one)

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* 16. Enrollment Type (Check one)

Does the student have an IEP?

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* 17. Does the student have an IEP?

Date last updated

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* 18. Date last updated

Class Type (Check all that apply)

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* 19. Class Type (Check all that apply)

School Information

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* 20. School Information

Are you employed?

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* 21. Are you employed?

If yes,

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* 22. If yes,

Where?

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* 23. Where?

Are you participating in an Internship?

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* 24. Are you participating in an Internship?

Who (if needed) will support you?

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

Emergency Contact (besides DFCS/ILP/Agencies)

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

Marital or Commitment Status:

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* 27. Marital or Commitment Status:

Do you have children?

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* 28. Do you have children?

Additional Child Information

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* 29. Additional Child Information

Minority Groups (Check all that apply)

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* 30. Minority Groups (Check all that apply)

Individualized Development Account (IDA)

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* 31. Individualized Development Account (IDA)

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

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* 32. Matched out for:

Have you completed any financial education?

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* 33. Have you completed any financial education?

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

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

Do you have health insurance?

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* 35. Do you have health insurance?

If yes, who is the provider?

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* 36. If yes, who is the provider?

Permanency Plan (what is your permanency plan)

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

I have a:

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* 38. I have a:

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

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

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

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

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

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

Please describe why you would join EmpowerMEnt?

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* 42. Please describe why you would join EmpowerMEnt?

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

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

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