Fill out this form with your needs for your child or children APPLICANT'S NAME * First Name Last Name GUARDIAN AD LITEM VOLUNTEER'S EMAIL ADDRESS * GUARDIAN AD LITEM VOLUNTEER'S PHONE NUMBER * (###) ### #### GUARDIAN AD LITEM VOLUNTEER'S ADDRESS Address 1 Address 2 City State/Province Zip/Postal Code Country COUNTY * Lee County Collier County Charlotte County Hendry County Glades County COUNTY W/LEGAL JURISDICTION FOR CHILD * Lee County Collier County Charlotte County Hendry County Glades County CHILD'S NAME * First Name Last Name CHILD'S DATE OF BIRTH * MM DD YYYY CHILD'S GENDER Male Female Decline to Answer Other CAREGIVER'S NAME * First Name Last Name CAREGIVER'S EMAIL ADDRESS * *If this email is incorrect, your support may be delayed or forfeit* CONFIRM CAREGIVER'S EMAIL ADDRESS * *If this email is incorrect, your support may be delayed or forfeit* CAREGIVER'S ADDRESS Address 1 Address 2 City State/Province Zip/Postal Code Country CAREGIVER TYPE Foster Home Relative Caregiver Non-Relative Caregiver Shelter Reunified DATE CHILD WAS PLACED IN THE HOME/DATE CHILD REUNIFIED MM DD YYYY CAREGIVER'S PHONE NUMBER * (###) ### #### SPECIFY REQUEST * Bed Clothing Happier Birthday Camp Dance, Art, Gymnastics Or Music Lessons Sports Participation Club Participation Tutoring Other DESCRIBE THE NATURE OF THIS REQUEST * RETAILER PREFERENCE *Only applicable to clothing & happier birthday's Walmart Target GIFT CARD FORMAT PREFERENCE *Only applicable to clothing & happier birthday's Physical Digital CHILD ADVOCATE MANAGER * Ana Ruiz Catherine Dotson Christina Hoskins Chyna Bergevin Colleen O'Shea Dana Steele Danuta Richey Esteban Millan Glenn VonSkal Grace Abernethy Janice Watson John Gercvickas Kat Doule Kaylee Davis Katherine Doule Kendal Jimenez Lara Becraft Lia Denison Madelyn Schock Monce Smittle Pamela Mosley Patricia Hoppa Robert Lefever Robyn Thomas Suleyma Santizo Stephanie Burns Tracy Damon Vanessa Rubio Rita Caines Thank you!
