“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.”

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* 1. Today’s Date:

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* 2. Origin of Application:

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* 3. Applicant Information

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* 4. Contact Information

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

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* 6. Status:

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* 7. Are you alumni of foster care?

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* 8. Were you in foster care in Georgia?

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* 9. If No, what state?

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* 10. Were you in foster care:

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* 11. Foster Parent or Agency Information

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

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

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* 14. Type of Current School Enrollment/Status

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* 15. Enrollment Location (Check one)

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* 16. Enrollment Type (Check one)

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* 17. Does the student have an IEP?

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* 18. Date last updated

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* 19. Class Type (Check all that apply)

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* 20. School Information

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* 21. Are you employed?

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* 22. If yes,

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* 23. Where?

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* 24. Are you participating in an Internship?

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

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

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* 27. Marital or Commitment Status:

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* 28. Do you have children?

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* 29. Additional Child Information

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* 30. Minority Groups (Check all that apply)

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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?

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* 32. Matched out for:

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* 33. Have you completed any financial education?

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

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* 35. Do you have health insurance?

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* 36. If yes, who is the provider?

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

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* 38. I have a:

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

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

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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?

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* 42. Please describe why you would join EmpowerMEnt?

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

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