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Kansas Department for Children & Families

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REQUESTOR INFORMATION
First Name*
Middle Name
Last Name*
Legal name while in custody, if different
than current name

Date Of Birth* (mm/dd/yyyy)
Social Security Number*

Mailing Address*
City*
State*
Zip Code*
Phone Number*
May we send text messages to this number?*

Email Address*
Gender
If Other, please specify



Race (Select all that apply)
If Other, please specify







Ethnicity

In which child welfare or juvenile justice system did you experience custody? (select all that apply)






In what state(s) were you in custody? (select all that apply)

(Press Ctrl key to select multiple states)

When were you in custody? Please estimate if you do not know the exact dates. If you experienced custoday on more than one occasion, please provide information for the most recent experience.

Start Date (mm/dd/yyyy)
End Date (mm/dd/yyyy)
How long were you in custody?
Highest Grade Level Completed
If Other, please specify

Do you have Children? (select all that apply)
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 pandemic affected you? (select each that apply)









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 pandemic relief 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*(Drivers License, State ID)



Read before signing::
I understand and authorize the Kansas Department for Children and Families to verify my former legal custody status and associated dates with the State Child Welfare System, Tribal Authority or Juvenile Justice System of record.

I understand that the information which I have authorized to be disclosed will be used for the purpose of determining my eligibility. I acknowledge that it is my responsibility to be aware of any rights of confidentiality which I may have regarding the information which I am releasing and that by signing this consent I am waiving my rights, if any, to confidentiality for purposes which I have approved.

If I have authorized the release of information to a person or agency providing independent living or foster care services under contract with my associated State Child Welfare System, Tribal Authority or Juvenile Justice System of Record, I have also authorized release of the information to any person or agency providing that service under sub-contract.

This consent may be revoked in writing at any time prior to any action which has been taken in reliance upon it.

This authorization will expire on 9-30-2021.


Signature*
Date