Dreamers and Believers Young Adult Application (Ages 16-26)

Choose the Following

Which one are you applying for:*

Select Role

The person completing this form is a:*

Enter Youth or Young Adult's Information

Young Adult's Name*

First Last

Young Adult's Date of Birth*

Young Adult's Last 4 digits of Social Security #*

Young Adult's Phone*

Young Adult's Email*

Is there a kinship or resource caregiver?

Yes
No

Enter Caregiver's Information

Caregiver's Name*

First Last

Caregiver's Phone*

Caregiver Email*

Caregiver's Address*

Street Address Apt. #, Suite, etc. City State ZIP Code

Enter Your Information

Name*

First Last

Phone Number*

Your Email*

Local Office*

CASA Office*

Facility Name*

Enter Supportive Contact Information

My supportive contact is:*

If you selected "Other," please specify the role of the individual below.*

Supportive Contact's Name*

First Last

Supportive Contact's Phone Number*

Supportive Contact's Email*

Select Grant Type

What type of grant are you requesting?*

Item(s)
Experience(s)

Amount Requested (Max $750)*

Please explain the item or experience you are requesting.*

Request Item Documentation

Available Educational Supports*

Tuition Assistance—Up to $750.00 if balance remains at your postsecondary institution
Books—Up to $750.00. An itemized list of books, the book titles and their ISBN numbers must be included with application
Equipment— A list must be included with your application. Please include syllabus if listed.
Food Cards
Laptop*— PC (specific brand subject to change). 6GB – 8 GB Memory - 1TB Hard Drive - (approx. $750)
Printer*—Epson Expression Home XP 330 Small-in-One Printer (approx. $90)
School Supplies— List of item numbers (www.staples.com) must be included.
Tablet*
Transportation*

School Address*

School Name Address City State Zip Code

Tuition - Please provide a web link to your tuition invoice

AND/OR upload your tuition invoice*

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Please upload a list of books with the ISBN #s or your syllabus*

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Please upload a list and your syllabus if listed*

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Food Cards - Choose up to two*

Walmart Plastic Gift Cards (shipped to you)
Target Plastic Gift Cards (shipped to you)
Target E-Gift Cards (emailed to you)

Laptop - Please provide a web link to the item of interest including cost and product description

Printer - Please provide a web link to the item of interest including cost and product description

Please upload a list of supplies with item numbers (www.staples.com)*

Max. file size: 50 MB.

Tablet - Choose one*

Samsung – Galaxy Tablet S3 – 9.7” – 32GB – Black (approx. $500)
iPad Wi-Fi with 128GB Memory (approx. $500)

Tablet - Please provide a web link to the item of interest including cost and product description

Transportation - Choose one*

Exxon Gas Gift Cards
Gulf Gas Gift Cards
Wawa Gas Gift Cards

Amazon Items - Please Attach Available Documentation To Show Items Requested (Scan of Shopping Cart, Screenshot of the Item(s), etc.).

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Or Add Link(s) to Receipt or Document Below
Note: If requesting items through Amazon, please drop the Amazon link with a list of the exact items you are requesting. The list should include complete product details such as size, color, style, quantity, and any other relevant specifications. If you’re making a list to send to us, make sure that anyone else who sees it should have view‑only access so no one accidentally adds extra items. To learn how to create a list on Amazon, refer to instructions here.

Link 1

Link 2

Link 3

Link 4

Link 5

Shipping Address

Same as caregiver's address
Use a different address

Shipping Address

Shipping Name*

First Last

Shipping Address*

Street Address Apt. #, Suite, etc. City State ZIP Code

Request Experience Vendor Documentation

Vendor 1/Service Provider's Name*

Vendor 1/Service Provider's Phone Number*

Vendor 1/Service Provider's Email*

Vendor 1/Service Provider's Address*

Street Address Apt. #, Suite, etc. City State ZIP Code

Vendor 1/Service Provider's Website

Vendor 1- Upload documentation showing the cost of the activity (flyer, brochure, invoice) -OR- enter vendor's website above (if you haven't already).

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Please note: We are allowing up to two vendors for this request. If you would like to add a second vendor, please provide their information below.

Vendor 2/Service Provider's Name

Vendor 2/Service Provider's Phone Number

Vendor 2/Service Provider's Email

Vendor 2/Service Provider's Address

Street Address Apt. #, Suite, etc. City State ZIP Code

Vendor 2/Service Provider's Website

Vendor 2- Upload documentation showing the cost of the activity (flyer, brochure, invoice) -OR- enter vendor's website above (if you haven't already).

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Enter Caseworker's Information

Caseworker's Name*

First Last

Caseworker's Phone*

Caseworker's Email*

Caseworker's Local Office*

Select Camp Experience

Are you choosing a 1 week or 2 week camp program?*

Please note: This request will use $500. You cannot request another $250 item as our policy allows one camp program per request

Please note: This request will use the full $750.

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Amount - $500

This field is hidden when viewing the form

Amount - $750

Explanation

Please explain why your child would like to attend camp*

Acknowledgement

Consent*

I have read and agree to all rules and disclaimers listed below.

ITEMS

• The item(s) I am requesting are for the youth in care and will travel with the youth if they reunify, move to another placement, or are removed from my home for any reason.

• I acknowledge that returns are not allowed unless for exceptional circumstances.

EXPERIENCES

• I understand embrella may make payments to vendors by check or credit card. If payment is made by credit card, the total cost may not include any additional fees or taxes.

• I understand that all refunds must be issued either to the embrella credit card used for the original purchase or as a check made payable to “embrella” and mailed to the embrella office.

CAMP JOHNSONBURG

• I understand embrella will make payments to camp by check.

• I understand that all refunds must be issued as a check made payable to “embrella” and mailed to the embrella office.

• I understand that if I need to cancel, it will be according to Camp Johnsonburg's cancellation policy.

• If my child does not show up at camp, I understand that I will not be able to request any additional Dreamers and Believers funds this year.

Signature*

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Submit Form

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Dreamers and Believers Youth & Young Adult Application (Age 16 - 26)

Choose the Following

Select Role

Enter Youth or Young Adult's Information

Enter Caregiver's Information

Enter Your Information

Enter Supportive Contact Information

Select Grant Type

Request Item Documentation

Shipping Address

Request Experience Vendor Documentation

Enter Caseworker's Information

Select Camp Experience

Explanation

Acknowledgement

Submit Form