Required Information

This form is to be completed prior to age 21 by any young adult 18 years of age or older who has exited state custody from Foster Care (at or after the 18th birthday) and wishes to request re-establishment of Foster Care Services. The form may be turned in to any DCS county office in the region the young adult lives in. That area’s designated Regional staff along with the Office of Independent Living will review the application and case record to determine eligibility.

Please Print Clearly

Date: ______

Required Information

Full Name: ______Social Security Number: ______-____-______

Date of Birth: ______Age: ______

Address______

(City) State Zip Code

Telephone Number: (____) ______

Cell Phone: (_____) ______

Emergency Contact Person: ______

Address: ______

Telephone: ______

E-mail Address: ______

Current Living Arrangement:

Dorm Apartment Former Foster Home Temporary Housing Homeless Other

Explain anything else you would like us to know about your current living arrangement: ______

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Current educational program (Please include progress, special needs): ______

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Are you currently employed? Yes No

If yes, please include name of current employer and length of employment: ______

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FORMER DCS CASE MANAGER’S INFORMATION (if known):

Name: ______e-mail address: ______

County______Office Phone Number :(____) ______

Office Fax Number: (_____) ______Supervisor’s Name______

Supervisor’s Telephone Number: (_____) ______

Please Indicate Your Status When You Exited State Custody

I turned 18 years of age while in state custody

I exited state custody before I turned 18 years of age

I was in Juvenile Justice status while in state custody

Additional Comments (educational goals, special circumstances, incentives applied for, urgent needs, etc.):

____________

I understand that I may be able to receive the following, if eligible:

·  An individualized Life Skills Assessment of my strengths and needs, if I ask for one.

·  An assigned Family Service Worker or other staff to help me meet my needs, who will see me according to policy.

·  A Transition Plan developed with help from the Family Service Worker (using assessment results, as applicable).

·  Review and update of my Transition Plan annually or more often if circumstances warrant it.

·  Life skills training which may include classroom instruction, workshops, and online instructional opportunities.

·  Assistance with pursuing goals related to achievement of a high school diploma, a graduate equivalency diploma (GED), post-secondary education to include programs that remove barriers to gainful employment, or services related to a disability.

·  Monetary assistance through IL Wraparound Funding, placement or other housing support, and the Chafee Education and Training Voucher or the Bright Futures (State Funded) Scholarship (as applicable per policy).

·  Continued court oversight to help ensure that I am receiving services that I need, either through foster care review board or a judge; this includes advance notice of review dates.

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Young Adult’s Signature Date

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Regional Administrator/Designee Signature Date

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IL Program Director/Designee Signature Date

Application is: Approved Denied

Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval.

Distribution: Regional Administrator, Independent Living Director/Designee, Young Adult, Extension of Foster Care File

CS- 0778 Page 1

Rev. 04/14 RDA 2982