Least of These Carolinas Request Form

Request Type

Relationship to Child

Relationship to the Child of the Adult Completing the Form

Request forms should only be completed by the child's current caregiver or their DSS Social Worker.

Does the child currently have an open case with the Department of Social Services (DSS)?

Yes No

Caregiver Information

▼

First Name

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

Can't find your address? Enter it manually

Is the caregiver a licensed foster parent?

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

DSS Social Worker Information

▼

First Name

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

Who should we contact when the item is ready for pickup?

Who will be picking up the item?

Pick Up Location

Selected:

Child Information

Child's First Name

Child's Last Name

Name the Child goes by

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.

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

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Before You Begin

Required Information

Least of These Carolinas