Dreamers and Believers Youth In Care Application (Ages 0-15)

Choose the Following

Which one are you applying for:*

Please note: This request is for the full $500.

Select Role

The person completing this form is a:*

Enter Child or Youth's Information

Youth's Name*

First Last

Date of Birth*

Youth's Phone Number

Youth's Email

Is there a resource or kinship caregiver?*

Yes
No

Enter Your Information

Name*

First Last

Your Phone Number*

Your Email Address*

Local Office (e.g., Mercer North Local Office)*

CASA Office*

Facility Name*

Enter Supportive Contact's Information

My supportive contact is a:*

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*

Local Office*

CASA Office*

Treatment Facility Name*

Enter Caregiver’s Information

Caregiver's Name*

First Last

Caregiver's Phone Number*

Caregiver's Email*

Caregiver's Address*

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

Select Grant Type

What type of grant are your requesting?*

Item(s)
Experience(s)

How Much Money are you Requesting? (Max $500)*

Please explain the item(s) or experience you are requesting.*

Request Amazon Item(s) Documentation

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 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).

Drop files here or

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).

Drop files here or

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

Enter Caseworker's Information

Caseworker's Name*

First Last

Caseworker's Phone Number*

Caseworker's Email*

Caseworker's Local Office*

This field is hidden when viewing the form

Amount- $500

Explanation

Please explain why your child would like to attend camp*

Acknowledgement

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

I agree

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

CAPTCHA

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Record Type Automation

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Household

Dreamers and Believers Youth In Care Application (Age 0 - 15)

Choose the Following

Select Role

Enter Child or Youth's Information

Enter Your Information

Enter Supportive Contact's Information

Enter Caregiver’s Information

Select Grant Type

Request Amazon Item(s) Documentation

Request Experience Vendor Documentation

Enter Caseworker's Information

Explanation

Acknowledgement

Submit