Caregiver Permission to Contact Form
The New York State Kinship Navigator is a state-wide program that provides information/assistance to kinship families and connects them with specialized services designed to support and help anyone who is raising someone else’s child.
If you sign this form and give your permission, the Kinship Navigator staff will contact you about its services and about local kinship services in your area.
With your permission,
we will call you!
If you have questions about Kinship Navigator services, please call 877-454-6463 or email .
Go to the back side of this page, where you'll find the permission to contact form.
Permission for Kinship Navigator to Contact Caregiver
Please check, sign and complete permission and contact information below,
and then return to your staff person
Permission for Kinship Navigator to call you: Yes No (If No, Stop here)
Currently working with kinship program at
Family Enrichment Network? Yes No
Signature: ______Date: ______
1. Name of Primary Caregiver: ______
2. Mailing Address: ______Apt Number: ______
City: ______State: ______Zip: ______
3. Home Phone: Area code: ______phone: ______- ______
4. Cell Phone: Area code: ______phone: ______- ______
5. Other Phone: Area code: ______phone: ______- ______
6. Email Address: ______
7. What language do you prefer? English Spanish
8. Preferences for contact (check all that apply)
Time of day: Morning (9-12) Lunchtime (12-1) Afternoon (1-4) Evening (4-6)
By: Email Mail Home Phone Cell Phone
______
Instructions for Staff: Please complete the information below, and fax this form to 585-454-6286 or email to . Please store all completed forms for pick up by Kinship Navigator project coordinator.
County: ______Staff Person: ______
Organization/Agency: ______Unit/Supervisor: ______
Date fax/email sent: ____/____/____
If caregiver declined to be contacted, please check box.
(Please fax the form even if caregiver declined to be contacted; this is important for our records).
KINSHIP NAVIGATOR COUNTY OUTREACH PROJECT Page 1