Request For Assistance

Youth in Foster Care or Living With Relatives

For questions or for help filling out form, please contact csalamacha@missionwv.org or call Cheryl Salamacha at 304-562-0723.

Please list name of youth and date of birth/age for each child you are requesting assitance for

Contact Information For Youth

Phone, Email, Mailing Address

Please provide the name of adult filling out form (youth's caregiver, Social Worker or School Personel)

What is your relationship to the youth?

Contact information of Adult filling out form:

Please provide phone, email or how you want to be contacted

Is Youth currently in DHHR custody?

Yes

Is Youth an active participant in the Modify Program?

Yes

If you marked yes, what is the Modify workers name?

Category of Need

Examples for each category can include but not limited to..... Extra Curricular Actives examples: Camp / Sport Fees or Sports Equipment - Lessons Necessities examples: Food, Clothing, Beds, Bedding, Safety Items, Hygiene Items Baby Items examples: Car Seat Family Traditions / Celebrations examples: Family visitation, assistance

Please provide a statement of what assistance you are requesting and what efforts you have made to meet your needs:

If you are requesting monetary assistance what is the amount you are requesting?

Please provide the name / mailing address for check

*Additional invoices/documentation may be required

If you are requesting a specific item what is the Amazon or other web link to the item?

You must agree to the following Disclaimers and electronically sign below:

Disclaimer

I agree not to use the card/funds for the following purchases: Alcohol, Tobacco or Firearms.

Disclaimer

I agree that, if the children leave my home/care, the items above belong to the children and will accompany them to their new placement.

Disclaimer

I agree not to sell, return, exchange or trade above items.

Electronically Signed By: