Apply For Assistance

The program will serve North Central Florida and will focus on providing families the opportunity to go apply for and receive financial advances to cover additional costs at various points in the process of assisting at risk children.

Please complete the form below if you are a parent, relative, non-relative, or foster parent needing assistance and submit to [email protected].

Apply For Assistance

Client Name *

Your Email *

Street Address

City

State/Province

ZIP / Postal Code

Country

Your Phone Number

How many children are you seeking to assist?

Please enter all child details below. By clicking on "Add New Child Detail" button you can add another child details. Please add all children details that you specify in above field.

Child Name

Child Age

Child Gender

Briefly describe how you will utilize this grant for the child/children

How much are you requesting for this grant?

Have you requested this grant in the past? *

when?

Please provide which agency are you being referred from? (ie. Partnership for Strong Families)

Name of Referring Agency

City of Referring Agency

State of Referring Agency

Please provide the name, phone number and email for your contact person with the agency.

Contact Name at Agency *

Contact email address *

Contact phone number

Please check that you will give a receipt within 2 weeks of receiving the grant. Yes I agree