LEADS Program Application

The LEADS program offers all youth in Grades 9-12 currently in foster care in Fulton and DeKalb Counties the opportunity to have educational supports guided by individual youth voice and choice.

Youth are eligible for LEADS if in the custody of Fulton County DFCS or DeKalb County DFCS. The youth must be in 9^ththrough 12^th grade, or currently pursuing their GED.

You will need to download and complete the LEADS Release of Information Form prior to submitting this application - please download it by clicking here.

If your youth is in DFCS custody but does not meet this criteria, email admissions@maac4kids.org for assistance in connecting with the appropriate point of contact for EPAC support.

STUDENT IDENTIFICATION

Last Name: *

First Name: *

Age:

Date of Birth: (mm/dd/yyyy) *

Race/Ethnicity: *

Gender *

Sexual Orientation

Is this youth in DFCS custody? * 🛈

Yes

No

Custody County: *

Case ID Number:

SHINES ID/Person ID/FCC Number:

GT ID Number:

SCHOOL INFORMATION

Name of School Attending:

School Type:

If in GNETS school, please include the date they entered GNETS:

Current Grade Level: * 🛈

Target Grade Level: 🛈

IEP Primary Eligibility:

CCI:

Yes

No

IEP:

Yes

No

504 Plan:

Yes

No

Gifted:

Yes

No

Educational Neglect:

Yes

No

Did Youth Enter Care Due to Educational Neglect?

Yes

No

Current Educational Needs:

Current Educational Supports in Place:

REFERRAL SOURCE - Name and Contact for Individual Completing Form

First Name: *

Last Name: *

Phone Number: *

Email Address:

Please upload the completed LEADS Release of Information form here: *

FOSTER CARE PLACEMENT INFORMATION

Placement/Caregiver First Name: *

Placement/Caregiver Last Name: *

Caregiver Phone Number: *

Caregiver Email Address:

Role/Relationship to Youth:

Street Address:

PO Box/Apt #:

City:

State:

Zipcode:

Boarding County:

Youth Phone Number:

Youth Email Address:

CASE MANAGER INFORMATION

First Name: *

Last Name: *

Phone Number: *

Email Address: *