Fosters Foundation

REFER A CHILD
Please fill out the following information to refer a child to our organization for support. If contacted by Fosters Foundation, please be prepared to submitt a brief written summary via email about why this child/family needs and deserves our help and support.
Child's Name:
Child's Age:
Parent/Guardian Name:
Child's Condition/Illness:
Child's Address:
City, State & Zip:
Parent/Guardian Address:
City, State & Zip:
Contact Phone:
Alt Phone:
E-mail:
Name of Person Referring Child:
Total # of Household Members:
What are the Child's Interests/Hobbies?:
Is the Child Wheelchair Bound?:	Yes No
Is the Child Bedridden?:	Yes No
Can the Child Travel?:	Yes No

When you click the "I Agree and Send" button a message will appear asking if you would like to continue,
click "Ok" to send the information via your email. By clicking "I Agree and Send", you agree to have your
information reviewed by our organization. We will not sell or dsitrubute your personal information to anyone
outside our organization.