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Kansas Department for Children & Families

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Request Form


 
REQUESTOR INFORMATION
First Name*
Middle Name
Last Name*
Legal name while in custody, if different than current name
Date Of Birth*
SSN*
Mailing Address*
City*
State*
Zip Code*
Phone Number*
Permission to send text messages to this number, if needed?*
Email Address*
Gender
If Other, please specify
Race (Select all that apply)






If Other, please specify

Ethnicity

Highest Grade Level Completed
If Other, please specify
Do you have Children?
   
If yes, how many?

Would you like us to send you information on services you may be eligible for? We will send information to you via email

Would you like us to send you information on opportunities to be involved in child welfare and/or juvenile justice advocacy or workgroups? We will send information to you via email


How has COVID-19 affected you?









If you feel comfortable, please include additional information on how COVID-19 and the pandemic have affected you and your life.


What areas of your life would this payment help you with? (Check all that apply):









File Uploads
*File size should be less than 50MB.
*Allowed file types: .doc;.docx;.pdf;.xlsx;.txt;.png;.jpg;.jpeg; only.
*Do not use special characters(like #,$,%,@,*,/,..)in the file name.

'Photo ID' Copy*




Signature*
Date