Least of These Carolinas Request Form

Request Type

Relationship to Child

Relationship to the Child of the Adult Completing the Form

Caregiver Information

▼

First Name

Middle Initial

Last Name

Mobile Number (For status updates)

I do not have a mobile number

Do you know the Caregiver's email address?

Yes No

Caregiver's Address

Is the caregiver a licensed foster parent?

Caregiver's Licensing Agency The agency that licensed the foster caregiver.

DSS Social Worker Information

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First Name

Middle Initial

Last Name

Mobile Number (For status updates)

I do not have a mobile number

Can the Social Worker receive text messages

Social Worker's Email

Social Worker county of employment

Request Details

Completion Contact - Who should we contact when the request is ready?

Pick Up Location

Selected:

Child Information

Child's First Name

Child's Last Name

Child's Placement Type

Group Home Name Select the group home where the child is placed.

Group Home Main Phone Number Main contact number for the group home.

Name the Child goes by

Child's Gender

Child's Date of Birth

Age of Child (Auto-calculated)

Child's Ethnicity

Child's Clothing Sizes

Required for Bags of Hope requests

Child's Shirt Size

Child's Pant Size

Child's Sock/Shoe Size

Child's Undergarments Size

Child's Diaper Size

Additional Information

Additional Information (Required for General Request and Just Like You Scholarship)

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Before You Begin

Required Information

Least of These Carolinas