Request For Assistance - Former Foster Youth

Funding for Kids in Transition Ages 16 and Older

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

Name

First Name

Last Name

Date of Birth

YYYY

Contact Information

Phone, Email, Mailing Address

Social Worker (Former or current)

Name

Contact Information

Category of Need

Please provide a statement of what assistance you are requesting and how it will assist you in your goals of independent living:

What steps have you taken to meet this need on your own?

If you are asking for monetary assistance, what amount are you requesting?

Please provide 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?

Additional Comments:

It is at the discretion of Mission WV to request additional information and to approve or deny requests. You must agree to the following Disclaimers and electronically sign below:

Disclaimer and Statement of Misuse

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

Disclaimer and Statement of Misuse

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 and Statement of Misuse

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

Electronically Signed By: