Extended Foster Care Resource Request Form

Completing this form is NOT a guarantee of assistance. The form will be sent to kerri@jamessamaritan.org upon submission. Please allow one week for consideration before receiving a response. 

Note 1: Our first priority at James Samaritan is to help youth from hard places build relationships and connections to their community that will make a lasting impact on their future. In keeping with this mission, priority will be given to young adults who are participating in our relationship building programs. 

Note 2: James Samaritan is NOT able to accept requests that are urgent in nature. Requests for housing, rental assistance, hotels, utilities, transportation, and other urgent needs or ongoing needs will not be considered as we do not have the capacity to meet needs at this level.

Thank you for your dedication in serving children and families from hard places. We appreciate any feedback you may have about this process or about how James Samaritan has impacted a client in a positive way.


Email *
Caseworker Name *
Caseworker phone number and email address *
Client's Name *
Client's Address and Phone Number *
Can the client receive large deliveries at the address above? *
Race or Ethnicity (check all that apply) *
Required
Has James Samaritan fulfilled a request for resources for this client within the past 12 months? *
Required
James Samaritan Programs this client has participated in over the past year (check all that apply) *
Required
Please describe the type of assistance you are requesting below (BE VERY SPECIFIC-include sizes,  colors, quantities, etc.): *
Please describe the special circumstances that prompted you to request this assistance. What is the hardship? What lead to this becoming a need? *
Will this resource help facilitate a foster youth moving out on their own for the first time? *
Required
Is this client currently enrolled in any other program to assist with these needs? *
Required
Your feedback on our programs or our process for requesting resources is welcome. All feedback is helpful. Please let us know how we are doing below.
A copy of your responses will be emailed to .
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