Oregon Youth Help Request

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Contact 1

First Name

Last Name

Any other names you've gone by

Date of Birth (MM/DD/YYYY)

Phone Number *

Would you like to receive text message updates? (fees may apply)

Yes

Receive updates from FosterClub?

Yes

Mailing Address

City

State

Zip Code

Facebook URL (Optional)

Instagram Username (Optional)

Twitter Handle (Optional)

TikTok Username (Optional)

Are you currently in foster care? *

Yes

Unsure

How old were you when you left the foster care system? *

Where did you experience the foster care system? *

Are you currently in Independent Living Program/Services (ILP)? *

Yes

Unsure

Do you have a caseworker or ILP provider? If so, please include their name and contact information. Otherwise, put NA.

Proposed discretionary/emergency expenditures

Please note: you will be asked to provide documentation to verify expenses. This can include bills, repair estimates, an online shopping cart with items, receipts, leases, and/or a budget.

To speed up the process, you may email documentation to [email protected] when you submit your request.

ETV - College/Post-secondary & Vocational Training costs (room/board, supplies, internet, transportation, etc.) $

Housing start-up (bedding, towels, kitchen utensils, food staples, etc.) $

Special work equipment (tools, uniforms, etc.) ..... $

Transportation (bus fees, vehicle repairs, auto insurance, driver’s education, etc.) ..... $

One-time move-in fees (rent, deposits: cleaning, utility, security) ..... $

Personal documents (Oregon ID, driver’s license, birth certificate, etc.) ..... $

Tutor (private and institutional; i.e., Sylvan Learning Center) ..... $

Secondary education costs (GED or SAT fees, application fees, sports fees, etc.) ..... $

Wellness Activities (identify) ..... $

Other (identify) ..... $

Please provide describe the 'other' expense:

Please advise which of the following best describes your situation (check all that apply):

What have the biggest pressures on your life in the past three months (check all that apply):

Provide a description of how the requested funds will be used and how they will assist you to improve your current life circumstances: *

Payment request type: *

Electronic Payment (PayPal, Zelle, etc.)

Check

Please note that for larger sums, electronic payment might not be available. Please contact us at 503-717-1552 if you have any questions regarding this.

What is the mailing address for a check?

What method of electronic payment works? What is your username?

Please list whatever forms of electronic payments you can receive and your user name. For example: PayPal: [email protected] Please note, we may not be able to send large amounts via CashApp or Venmo. We may request your email or cell phone # that is connected to your Zelle account to send payments.

Housing Payments: The young person understands an additional budget form is required when requesting housing funds. If young person is requesting on-going housing funds, a new budget document will be required each month to help determine financial support needed. The young adult may request assistance from the Young Adult Navigator, their ILP Provider, or other trusted resource. The Youth Transitions Program team is also available for assistance by email (include “COVID-19 Housing” on the subject line).

Agreement statement: The young person agrees that the costs are necessary to assist the young person to achieve or maintain the young person’s plan of independence. The young person will submit a statement/invoice for any on-going bill the funds are to assist with showing amount owed or monthly payment required.

For a young person who has requested funds for a driver’s course, by initialing below, the young person also agrees to allow ODHS to send their identifying information to the Oregon Department of Transportation. This will allow ODHS to receive a refund for driver courses a young person completes successfully.

Who is making the request for this young person? *

Self (youth)

Supportive Adult

Young person's signature (please type your name)

Adult supporter

If young person did not sign above, select the type of worker or supportive adult who assisted the young person complete the above request and understand the expectations listed above:

Worker/Supportive Adults Name:

Supportive Adult’s Agency/Role:

Supportive Adult’s E-Mail Address:

Supportive Adult’s Phone:

We'll jump right into looking at your request! Keep in mind - if you are submitting this on a weekend or in the evening when our office is closed, please allow some time for a FosterClubber to get back to you. You can also reach our office at 503-717-1552.

Oregon Youth Help Request

Youth Transitions Funding can assist with items, services, or extra-curricular activities that will help young people(age 14-23) achieve the goals identified in their transition plan while gaining life skills for a successful transition to adulthood.

Fill out the form below, or contact FosterClub at 503-717-1552 x115 for assistance.

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