DCFS Respite Request

Thank you for considering Connected Foster Care for respite. Please complete and submit this form to notify us you pursue your respite request. We will review the request and then contact you to confirm the respite. Thank you, and if you need assistance, please email our Director of Foster Placement, Rachel Hutchison.

Respite Request Details

Committed From Member (Arranging Respite) First Name This is required

Committed From Member (Arranging Respite) Last Name This is required

Estimated Respite Placement Region This is required

Your Name (DCFS Worker) First Name This is required

Your Name (DCFS Worker) Last Name This is required

Your Email Enter an email Use an address with (@) and (.)

Your Phone Enter your phone number Enter a valid number like +1555-123-4567

DCFS Supervisor First Name This is required

DCFS Supervisor Last Name This is required

DCFS Supervisor Email Enter an email Use an address with (@) and (.)

DCFS Supervisor Phone Enter your phone number Enter a valid number like +1555-123-4567

Respite Request Start Date This is required rt.advancedFormInput.date.formatMessage

Respite Request End Date This is required rt.advancedFormInput.date.formatMessage

County of Foster Home This is required

Current County of Placement This is required

Sibling 1

Sibling 1 First Name This is required

Sibling 1 Last Name This is required

Sibling 1 - Gender This is required

Sibling 1 - Date of Birth This is required rt.advancedFormInput.date.formatMessage

Sibling 1 - Age This is required Enter a phone number

Sibling 1 - DCFS Client ID Number This is required

Sibling 1 - SSN This is required

Sibling 1 - Medicaid or TANF/PASSE Provider and Member ID This is required

Sibling 1 - Please list any allergies, current medications, and medical conditions This is required

Sibling 1 - Please list the school, grade, and teacher (if applicable). What is the transportation plan to and from school? This is required

Sibling 1 - Describe any behavioral issues This is required

Sibling 2

If there are any other siblings who would be placed in respite with this sibling, please complete the information for each sibling. Otherwise, skip to the next section.

Sibling 2 First Name This is required

Sibling 2 Last Name This is required

Sibling 2 - Gender This is required

Sibling 2 - Date of Birth This is required rt.advancedFormInput.date.formatMessage

Sibling 2 - Age This is required Enter a phone number

Sibling 2 - DCFS Client ID Number This is required

Sibling 2 - SSN This is required

Sibling 2 - Medicaid or TANF/PASSE Provider and Member ID This is required

Sibling 2 - Please list any allergies, current medications, and medical conditions This is required

Sibling 2 - Please list the school, grade, and teacher (if applicable). What is the transportation plan to and from school? This is required

Sibling 2 - Describe any behavioral issues This is required

Sibling 3

Sibling 3 First Name This is required

Sibling 3 Last Name This is required

Sibling 3 - Gender This is required

Sibling 3 - Date of Birth This is required rt.advancedFormInput.date.formatMessage

Sibling 3 - Age This is required Enter a phone number

Sibling 3 - DCFS Client ID Number This is required

Sibling 3 - SSN This is required

Sibling 3 - Medicaid or TANF/PASSE Provider and Member ID This is required

Sibling 3 - Please list any allergies, current medications, and medical conditions This is required

Sibling 3 - Please list the school, grade, and teacher (if applicable). What is the transportation plan to and from school? This is required

Sibling 3 - Describe any behavioral issues This is required

Sibling 4

Sibling 4 First Name This is required

Sibling 4 Last Name This is required

Sibling 4 - Gender This is required

Sibling 4 - Date of Birth This is required rt.advancedFormInput.date.formatMessage

Sibling 4 - Age This is required Enter a phone number

Sibling 4 - DCFS Client ID Number This is required

Sibling 4 - SSN This is required

Sibling 4 - Medicaid or TANF/PASSE Provider and Member ID This is required

Sibling 4 - Please list any allergies, current medications, and medical conditions This is required

Sibling 4 - Please list the school, grade, and teacher (if applicable). What is the transportation plan to and from school? This is required

Sibling 4 - Describe any behavioral issues This is required

As the above-named qualified worker/representative of Arkansas Division of Children and Family Services (DCFS), I do hereby assure the above-named child(ren) will be placed in respite care with Connected Foster Care and that the above-named child(ren) will receive the care and services needed during the respite stay. I understand that DCFS remains responsible for the child(ren) and for the cost of any needed medical treatment, and I authorize Connected Foster Care to seek emergency medical care if needed. By typing my name below, I confirm this request is accurate and complete.

Please sign using your name: First Name This is required

Last Name This is required

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Thank you! Your respite request has been submitted.

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Thank you! Your respite request has been submitted.

As the above-named qualified worker/representative of Arkansas Division of Children and Family Services (DCFS), I do hereby place the abovenamed child/children with Arkansas Baptist Children & Family Ministries (Connected Foster Care) for the purpose of respite, not to exceed more than 14 days. DCFS gives consent to Connected Foster Care duly appointed representative(s) to assist the above-named child/children to receive any emergency/hospital treatment, medical treatment, psychological treatment, dental treatment, vision treatment, and/or hearing treatment as may be deemed necessary and expedient by a licensed physician or specialist. DCFS gives consent for the above-named child/children to travel within the state of Arkansas with Connected Foster Care duly appointed representative(s) and/or the respite Connected Foster Care resource families during the respite stay. DCFS gives consent and authorization for Connected Foster Care duly appointed representative(s) to enroll above-named child/children in school and serve in the capacity of guardian concerning academic or educational situations with the school if applicable. DCFS gives consent that while the above-named child/children is in the care of Connected Foster Care, the child will potentially attend church services and other functions of the respite Connected Foster Care resource families during the respite.

DCFS Respite Request

Respite Request Details

Sibling 1

Sibling 2

Sibling 3

Sibling 4

DCFS Respite Request

Connected Team Member Arranging Respite

Your Name (DCFS Worker)

DCFS Supervisor

Sibling 1

Sibling 2

Sibling 3

Sibling 4

Services

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