Share My Smile Family Enrollment

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Please include all information to register or update your family with Share My Smile

Please indicate if you are registering for the first time or updating.

Email *

Parent 1 Last Name, First Name *

Are you enrolling for the first time or updating your family record? *

First time!

Updating My Family

Parent 1 Birthdate 00/00/0000 *

Parent 1 Phone Number (xxx)-xxx-xxxx *

Home Address *

City *

State *

Zip *

What county do you live in? *

Parent 2 Last Name, First Name

Parent 2 Birthdate 00/00/0000

Parent 2 Email

Parent 2 Phone Number (xxx)-xxx-xxxx

When did you become licensed foster/adoptive parents? *

What agency is your foster license through?

Please proivde the first and last name of your current case worker.

List all foster children, including kinship and guardianship, 18 and under. Include initials of the child, sex, and birthday (initials, F/M, mm/dd/yyyy). Complete all requested information on each child or services could be delayed to obtain information. *

Do you have a child in need of a care bag? Please select the answer that applies to you.
*

Care for You Action provides care bags to foster youth (includes foster, kinship, and guardianship placements) entering a new home. Bags are equipped with hygienic necessities including bath soap, toothbrush/toothpaste, shampoo/conditioner, etc. and care items including a blanket, stuffed animal and a journal or coloring book. All items are provided in a brand new bag for your youth to call their own.

No, we do not have foster children in our home in need of a bag.

Yes, I have a new foster placement and need a bag.

Yes, I have a foster child in my home and though they are not new to our home, they have not received a bag and would benefit from one.

Required

List all adopted children 18 and under. Include name, sex, and birthday (name, F/M, mm/dd/yyyy). Complete all requested information on each child or services could be delayed to obtain information. *

List all biological children 18 and under. Include name, sex, and birthday (name, F/M, mm/dd/yyyy). Complete all requested information on each child or services could be delayed to obtain information. *

Please note that due to the nature of foster care, it is our current policy that the parent is responsible for keeping Share My Smile informed of the status of the foster children in the home in order to receive program benefits for these children. Thank you.

OPT IN/OPT OUT POLICY

By registering with Share My Smile and submitting this form, you agree to receive emails and text messages from Share My Smile. You will receive emails from info@sharemysmile.org. To opt out of receiving emails at any time, please respond with "UNSUBSCRIBE". To opt out of text messages at any time from 402-300-3112, reply "STOP".

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