If you have questions about the FosterClub Outstanding Young Leaders recognition program or would like assistance completing the form, please call 503-717-1552 or email KaylaM@fosterclub.com. Before Starting the ApplicationPlease read the FosterClub Audio, Photo & Video Agreement and select below if you agree. Agree to Media Release * I agree Youth Information Upload Photo Please submit a photo that can be published on our website.Files must be less than 2 MB.Allowed file types: gif jpg jpeg png. First Name * Last Name * Birthdate * Year Year199119921993199419951996199719981999 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 I identify my gender as * girl/woman boy/man transgender other Other I identify my race/ethnicity as African American Native American or Alaskan Native Native Hawaiian or Other Pacific Islander Asian Caucasian Hispanic or Latino Other Other States I was in care Contact info Address * Country - None -AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Phone Number * Alternative Phone Number Email Address * Facebook URL If you have a Facebook account, copy the web address from your own profile and paste it here. Personal Statement 1st Piece: Foster Care Background and Biography * Please include foster care experience (number of placements, and any challenges), achievements are you proud of, organizations you work with, current situation (attending school, working, and/or interning). Consider including a hobby or fun fact about yourself. (Limit 500 characters.) 2nd Piece: Community Service and Honors * Why do you deserve to be recognized as a FosterClub Outstanding Young Leader? Consider describing how you’ve given back in your community. You may list volunteer work, honors you’ve received for activities at school or church, leadership groups you participate in. (Limit 500 characters.) 3rd Piece: Future Plans * Share your education goals and career plans. What do you plan to achieve in the future? What do you dream about becoming in life? (Limit 500 characters) 4th Piece: Personal Quote * Why do you think giving back is important? (Try to limit to 1-2 sentences or a phrase.) Story ElementsPlease check items below that relate to your own personal story and that you are comfortable talking about. This is optional, but helps us connect you to future opportunities. Personal Experiences adopted wanted to be adopted but wasn't failed adoption reunified with parent immigration involved in my court process not involved in my court process lost my connection to cultural identity in foster care stolen identity before/during/after foster care (i.e. someone used your SSN) developmental disability struggle(d) with mental health issues took/take psychotropic medicine trouble with peer / romantic relationships because of foster care moved to multiple schools because of foster care incarcerated parent LGBTQ sex trafficking entry into foster care could have been prevented (i.e. if parent had more help) experienced substance abuse parental substance abuse juvenile justice or incarceration aged out of foster care homelessness separated from siblings other (please specify) Other Experiences If you selected other in personal experiences, please list them here. Placement Experiences foster home adoptive home relative (kindship) home group home residential facility such as a treatment center independent living program or transitional housing shelter on my own other (please specify) You may check all that apply. Other Placement If you selected other in placement experiences, please list that here.