Please provide as much information as possible. If you are submitting a
request for multiple children in the same household, please add
children in the “Additional Children Needing Services” section.

*Denotes required field

Date of Request*:
Name of Individual Submitting Request*:

Choose one*:
Spring BreakSummer CampWinter BreakOther

Child's Information

Child's Full Name*:
Child's Date of Birth*:
Child's Grade (2019-2020)*:
Additional Children Needing Services: (Provide full names, DOB and Gender):

Caregiver Information

Caregiver's Full Name*:
Relation to Child*:
Caregiver Phone Number*:
Caregiver Email*:
Caregiver Address*:

Caregiver City*:
Caregiver State*:
Caregiver Zip Code*:

Camp Information

Name of Camp*:
Camp Site Address*:
Camp Phone Number*:
Date Starting*:
Date Ending*:
Days Attending Per Week*:

Case Information

Case FSFN Number*:
County Case is Filed*:
Placement Status*:
Case Manager's Full Name*:
Case Manager Email*:
Case Manager Phone*:
Guardian ad Litem Full Name*:
Guardian ad Litem Email*:
Guardian ad Litem Phone*:


By submitting this form, you agree to the following:
o You will be responsible for providing or approving transportation to and from summer camp.
o FFCF must be notified of any children that are withdrawn or do not attend summer camp.
o You will be responsible for reimbursement if child does not attend or withdraws from summer camp.