Application form Step 1 of 3 33% Apply Eligibility is limited to children who are in the physical care and custody of the Massachusetts Department of Children and Families, and young adults 18 years or older who have voluntarily readmitted themselves into the care of the Massachusetts Department of Children and Families. The applicant may be required to provide proof of adjudication, or Voluntary Placement Agreement. Rise Above cannot make reimbursements of goods or services. Please note that incomplete applications will delay request processing, or may lead to a denial of request. Provide the following information about the child:Name* First Last Date of birth:* MM slash DD slash YYYY Gender:*--MaleFemaleTransgenderEthnicity: Hispanic or Latino Not Hispanic or Latino Race: American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Unknown Other Current city/town of residence:* Child’s placement type:* DCF foster home Kinship placement Comprehensive foster care (CFC) home Group home or residential program I’m not sure Other Specify Child’s DCF social worker:Full name:* Phone:Email address: DCF Area Office--Dimock Street Area Office (Roxbury)Hyde Park Area Office (Hyde Park)Harbor Area Office (Chelsea)Park Street Area Office (Dorchester)Arlington Area OfficeCoastal Area Office (Braintree)Cape Cod and Islands Area Office (Hyannis)Plymouth Area OfficeFall River Area OfficeNew Bedford Area OfficeBrockton Area OfficeTaunton/Attleboro Area OfficeGreater Lowell Area OfficeFramingham Area OfficeHaverhill Area Office (Bradford)Lawrence Area OfficeCambridge/Burlington Area OfficeMetro North Area OfficeCape Ann Area Office (Salem)Lynn Area OfficeWorcester East Area Office (West Boylston Dr.)Worcester West Area Office (Sudbury Street)South Central Area Office (Whitinsville)North Central Area Office (Leominster)Greenfield/Northampton Area OfficeHolyoke Area OfficeSpringfield Area Office (High Street)Robert Van Wart Center (Springfield)Berkshire Area Office (Pittsfield)I’m not sureOtherSpecify Request InformationActivity being requested, description and reason/circumstance for the request:*Date needed by:* MM slash DD slash YYYY Amount requested:* Check / Payment Recipient (Checks must be made payable to the provider of the service. Rise Above cannot provide reimbursement)Other sources of funding soughtIs the child currently working?* Yes No If yes, is he/she able to contribute?* What other sources of funding have been explored for this request?* (Other sources of funding must be explored before applying to Rise Above, especially DCF funds, CFC enrichment funds, PNA accounts, community resources.)Applicant informationFull Name:* Phone:*Email:* Relationship to foster child*--Youth- I’m applying for me!DCF social workerFoster parentCase worker or clinicianOther support (specify)Specify StatementBy making, or joining in making, this request, the undersigned states that he/she has investigated alternative resources to fulfill the request listed above and that no reasonable alternatives are available. Awards are limited and provided on a first-come first-serve award appropriate basis, until exhausted. Upon approval, funding of awards will be facilitated by Rise Above in a form designated and solely determined by the Application Review Committee. Please note that if the applicant is not the DCF social worker, the applicant must receive the consent of the DCF social worker in order to submit this application. Rise Above will contact the DCF social worker to verify consent, and certain information contained herein. Rise Above is committed to processing application requests in a reasonably appropriate amount of time. FOR APPLICANTS OTHER THAN DCF SOCIAL WORKERS: BY TYPING MY NAME BELOW I CERTIFY THAT MY / THE CHILD’S DCF SOCIAL WORKER IS AWARE OF AND CONSENTED TO THE SUBMISSION OF THIS APPLICATION. Also by signing you acknowledge that Rise Above takes precautions to ensure all data submitted is secure, but cannot be held liable if data is compromised. Electronic Signature:* Δ
