Something Special, Inc -- Application Form

Applicant's Information

Name: Birthday: Male Female

Street: City: State: Zip Code:

How long has the child lived at this address? Phone Number:

Placement Type:
Co. Foster Home FFA Home Group Home Kinship Care

If FFA or group home, please list the name of the organization:

How Long has the child been in foster care?
(total number of months including previous and current placements)

Child's Status:
Family Reunification Longterm Care Adoption/Guardianship

Caregiver's Information

Name: Phone Number: Email:

Street: City: State: Zip Code:

Relationship to Child:

Information about Award Requested

1. What interest or talent are you trying to start or develop further? (Provide as much detail as possible about the musical, artistic, or athletic pursuit)

2. What have you done so far to develop this interest or talent?

3. What specific equipment or services (lessons) are you requesting? Please explain how it will support the development of your interest. (The more detail we have, the better we are able to evaluate your request.)

4. Please tell us how we can follow up with you to learn if our support helped you develop your talent or interest.

5. If there a sign-up deadline associated with your request, please enter the date of the deadline:

6. Please tell us how you heard about Something Special.

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