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Georgia EmpowerMEnt Application
Applicant Information
Legal Name:
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Preferred Name:
DOB:
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Gender:
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Female
Male
Trans Female
Trans Male
Gender Queer/Gender Non-Conforming
Different Identity
Race/Ethnicity:
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White/Caucasian
Black/African American
Native American or Alaskan
Asian or Pacific Islander
Hispanic
Multi-Racial
Unable to Determine
Other
Sexual Orientation
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Heterosexual
Gay
Lesbian
Bisexual
Questioning
Other
Phone Number:
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Email Address:
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DFCS Region:
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Status:
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18-21 (Extended Care)
Adopted
DJJ
Kinship/Guardianship
With Biological Parents
Youth in Foster Care
Were you in foster care in GA? If not, which state?
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County:
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County You Came Into Care:
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Caseworker Name:
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Current Placement Type
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Couch surfing; moving from house to house
Homeless (Including living on the street or homeless shelter)
Living in a Foster Home
Living in a group setting (Group Home, Residential, or Residential Treatment Facility)
Living in a school dormitory or apartment
Living independently (Not an ILP; your name on the lease)
Living with family (Birth parents, adoptive parents, legal guardian, or other relatives)
Transitional Living Program or Independent Living Program
Education Information
Enrollment Status:
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Public School
Private School
Home School
GED Program
HS Graduate
GED Graduate
Tech/Vocational School
2-Year College
4-Year College
College Graduate
Not Enrolled
School Name:
School County:
School Address:
Employment Information
Are you employed?
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Yes
No
Employment Status
Full-Time
Part-Time
Internship
Employer:
Emergency Contact
Name:
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Relationship:
Phone Number:
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Name:
Relationship:
Phone Number:
Family
Marital Status
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Single
Married
Dating
Domestic Partner
Do you have children?
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Yes
No
If so, what are their ages:
Life Experience
Check all that apply:
A person for whom English is a second language
A person who has received services through the DJJ
A person who identifies as LGBTQ
A person with a diagnosis of a developmental disability
A person with a mental health diagnosis or service history
A person who has experienced homelessness
Running away
Individualized Development Account (IDA)
Do you know about IDA?
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Yes
No
Do you have an IDA account?
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Yes
No
Have you had your credit checked?
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Yes
No
Not Sure
Healthcare - 18 and Over
Do you have insurance?
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Yes
No
Not Sure
Permanency Plan
What is your permanency plan?
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Adoption Finalized
Emancipation
Guardianship
Living w/Relative
Long-term Foster Care
Reunification
Not Sure
I have the following documentation:
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Birth Certificate
Driver's License
Learner's Permit
Other (Proof of Citizenship)
Social Security Card
State ID
Voter Registration
EmpowerMEnt Priorities
What areas are you interested in? Check all that apply:
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Advocacy for a network of caring, consistent permanent relationships and social capital
Continued efforts to improve relationships with case managers
Continued monitoring of Medicaid benefits up to 26th birthday
Continued monitoring of policy and practices regarding babies of youth in care remaining with their parents
Continued monitoring of supports for educational stability/stable school experience
Continued support and monitoring of Psychotropic Medication oversight
Designing and Developing appropriate foster care options for youth between ages 18-26
Foster youth need a stable school experience
Improved access and support to obtain driver's license
Monitoring of implementation of 2013 Juvenile Justice Reform legislation
Reduce homelessness among transitioning youth
Youth voice and choice in court hearing process
Other
Other
What forms of communication do you use?
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I have access to a landline phone
I have a cell phone
I have a smart phone
I have email access
I have texting
What are your strengths, talents, and gifts that make you unique?
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What do you need support or help with to be successful in transitioning out of foster care and reaching your goals?
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Why are you interested in joining EmpowerMEnt?
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