Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Is this your first Application submission with Embrace AL Kids' Support 4 Success program?</label><select name="CST_142"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 100%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">If yes, please continue and complete the application for submission. If you have previously completed an application with EMBRACE AL KIDS-Support 4 Success (this does not include prior applications made through Foster Care 2 Success), email s4s@embracealkids.org for log in access to your application. This will enable you to review your prior application and only make any necessary corrections or adjustments.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 50%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Application</label><input class="cst_datepicker er_fld_required" name="CST_1" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_FirstName"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_4" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_MiddleInitial"> <i class="fa fa-font"></i><label class="er_fld_label required">Middle Name</label><input name="CST_3" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" map_to="CC_LastName" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_2" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_Nickname" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Preferred Name</label><input name="CST_5" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 100%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Previous Names (as applicable-maiden, pre-adoptive, alias, prior married name, etc.)</label><textarea name="CST_24" style="width:100%;" class=""></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" map_to="CC_DOB" style="width: 50%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Birth</label><input class="cst_datepicker er_fld_required" name="CST_8" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="CC_Gender" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Gender</label><select name="CST_9" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Male">Male</option><option value="Female">Female</option><option value="Non Binary">Non Binary</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="CC_Race" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Race/Ethnicity</label><select name="CST_10" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="White/Caucasian">White/Caucasian</option><option value="Black/African American">Black/African American</option><option value="Mixed Race">Mixed Race</option><option value="Latino">Latino</option><option value="Native American">Native American</option><option value="Asian American">Asian American</option><option value="Pacific Islander">Pacific Islander</option><option value="Preferred not to say">Preferred not to say</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_10" er_fld_condvals="er_fld_showif_values=Other"> <i class="fa fa-font"></i><label class="er_fld_label required">Please enter your Race if you marked Other for "Race/Ethnicity"</label><input name="CST_15" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Do you have a Tribal Affiliation?</label><select name="CST_11" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_11" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label required">Please list the name of the tribe you are affiliated with.</label><input name="CST_12" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;" map_to="CC_PrimaryLanguage"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Primary Language</label><select name="CST_13" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="English">English</option><option value="Spanish">Spanish</option><option value="Other">Other</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Secondary Language</label><select name="CST_14" class=""><option value="- Not Specified -" selected="">- Not Specified -</option><option value="N/A">N/A</option><option value="English">English</option><option value="Spanish">Spanish</option><option value="Other">Other</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_13" er_fld_condvals="er_fld_showif_values=Other"> <i class="fa fa-font"></i><label class="er_fld_label required">Please enter your Primary Language if you selected "Other"</label><input name="CST_16" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;" map_to="CC_PersonalPhone"> <i class="fa fa-font"></i><label class="er_fld_label required">Cell Phone Number</label><input name="CST_17" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_PersonalEmail"> <i class="fa fa-font"></i><label class="er_fld_label required">Primary Email Address</label><input name="CST_19" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Secondary Email Address (optional)</label><input name="CST_22" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" map_to="none" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Citizenship Status</label><select name="CST_18" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="US Citizen">US Citizen</option><option value="Permanent Resident">Permanent Resident</option><option value="Unaccompanied Refugee Minor">Unaccompanied Refugee Minor</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 100%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Do you have a social security number?</label><select name="CST_81" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_81" er_fld_condvals="er_fld_showif_values=Yes" map_to="CC_SSN"> <i class="fa fa-font"></i><label class="er_fld_label required">Social Security Number</label><input name="CST_25" type="text" class="er_fld_required"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_81" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label required">A-Number</label><input name="CST_28" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Are you parenting a child?</label><select name="CST_29" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Are you currently married?</label><select name="CST_30" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Emergency Contact Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Name of Emergency Contact</label><input name="CST_31" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Contact Number</label><input name="CST_32" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Housing Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Mailing Address (Where you will have packages sent while attending school.)</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_School_Street_1" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Street Name & Number (include apartment number if applicable)</label><input name="CST_36" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" map_to="CC_School_City" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">City</label><input name="CST_37" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown" draggable="false" map_to="CC_School_State" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">State</label><select name="CST_42" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option></select></li><li class="er_fld_type_text" draggable="false" map_to="CC_School_Zip" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Zip Code</label><input name="CST_38" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false"><i class="fa fa-header"></i><label>Physical Residence Address (Where you will be living while attending school.)</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Type of Residence</label><select name="CST_49" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Dorm">Dorm</option><option value="Apartment">Apartment</option><option value="Fraternity/Sorority">Fraternity/Sorority</option><option value="Group Home">Group Home</option><option value="Adopted Family/Guardian Home">Adopted Family/Guardian Home</option><option value="Other">Other</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_49" er_fld_condvals="er_fld_showif_values=Other"> <i class="fa fa-font"></i><label class="er_fld_label required">Enter type of residence if you selected "Other"</label><input name="CST_50" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Is your physical address the same as your mailing address?</label><select name="CST_47" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_47" style="width: 50%;" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label required">Physical Address: Street Name & Number (include apartment number if applicable)</label><input name="CST_44" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_47" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label required">Physical Addres: City</label><input name="CST_45" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown er_fld_showif" draggable="false" er_fld_condfld="CST_47" er_fld_condvals="er_fld_showif_values=No" style="width: 25%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Physical Address: State</label><select name="CST_48" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_47" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label required">Physical Address: Zip</label><input name="CST_46" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Education Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">High School graduated/graduating from</label><input name="CST_51" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">High School City</label><input name="CST_52" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">High School State</label><select name="CST_53" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 50%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of High School Graduation/Anticipated Graduation OR GED Completion (month/year)</label><input class="cst_datepicker er_fld_required" name="CST_54" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Did you have and IEP/504 Plan in high school?</label><select name="CST_55" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option><option value="Unsure">Unsure</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif" draggable="false" er_fld_condfld="CST_55" er_fld_condvals="er_fld_showif_values=Yes" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">If you had and IEP/504 in high school, and are currently attending college, do you have a 504 plan?</label><select name="CST_56" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option><option value="Unsure">Unsure</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>College Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Are you currently enrolled and attending a college or vocational program?</label><select name="CST_152" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_text er_fld_selected er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_152" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label required">When do you plan to start attending a college or certification program (ex: Fall 2025)</label><input name="CST_153" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">What college or vocational school are you planning to attend or currently attending?</label><input name="CST_57" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">City of College or Vocational School</label><input name="CST_58" type="text" class="er_fld_required"></li><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">State of College or Vocational School</label><select name="CST_59" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Degree Field/Major/Certification you are seeking</label><input name="CST_60" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;"> <i class="fa fa-font"></i><label class="er_fld_label">If you are currently attending or planning to attend a second college/institution as part of a bridge program or to take additional classes, Additional College/Institution Name:</label><input name="CST_151" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Degree Type</label><select name="CST_61" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Associate's Degree">Associate's Degree</option><option value="Bachelor's Degree">Bachelor's Degree</option><option value="Certification">Certification</option><option value="Other">Other</option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_61" er_fld_condvals="er_fld_showif_values=Other"> <i class="fa fa-font"></i><label class="er_fld_label required">Degree Type (if selected "Other"</label><input name="CST_62" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 25%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Enrollment Plan</label><select name="CST_63" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Full Time">Full Time</option><option value="Part Time">Part Time</option><option value="Quarter Time">Quarter Time</option></select></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label required">How many credit hours have you already earned (if any)</label><input name="CST_64" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Anticipated Graduation date (ex: Spring 2027)</label><input name="CST_141" type="text" value="" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>FASFA Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Have you applied for Federal Financial Aid/FASFA</label><select name="CST_66" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_date er_fld_showif" draggable="false" er_fld_condfld="CST_66" er_fld_condvals="er_fld_showif_values=Yes" style="width: 50%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date Completed FASFA (month/year)</label><input class="cst_datepicker er_fld_required" name="CST_67" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" er_fld_condfld="CST_66" er_fld_condvals="er_fld_showif_values=No" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">If you have not completed the FASFA, please explain why</label><textarea name="CST_68" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Eligibility Determination Information</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">What state did you live in while you were in foster care?</label><select name="CST_69" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown er_fld_showif sortable-chosen" draggable="true" er_fld_condfld="CST_69" er_fld_condvals="er_fld_showif_values=Alabama" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">What county had your foster care case?</label><select name="CST_70" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Autauga">Autauga</option><option value="Baldwin">Baldwin</option><option value="Barbour">Barbour</option><option value="Bibb">Bibb</option><option value="Blount">Blount</option><option value="Bullock">Bullock</option><option value="Butler">Butler</option><option value="Calhoun">Calhoun</option><option value="Chambers">Chambers</option><option value="Cherokee">Cherokee</option><option value="Chilton">Chilton</option><option value="Choctaw">Choctaw</option><option value="Clarke">Clarke</option><option value="Clay">Clay</option><option value="Cleburne">Cleburne</option><option value="Coffee">Coffee</option><option value="Colbert">Colbert</option><option value="Conecuh">Conecuh</option><option value="Coosa">Coosa</option><option value="Covington">Covington</option><option value="Crenshaw">Crenshaw</option><option value="Cullman">Cullman</option><option value="Dale">Dale</option><option value="Dallas">Dallas</option><option value="DeKalb">DeKalb</option><option value="Elmore">Elmore</option><option value="Escambia">Escambia</option><option value="Etowah">Etowah</option><option value="Fayette">Fayette</option><option value="Franklin">Franklin</option><option value="Geneva">Geneva</option><option value="Greene">Greene</option><option value="Hale">Hale</option><option value="Henry">Henry</option><option value="Houston">Houston</option><option value="Jackson">Jackson</option><option value="Jefferson">Jefferson</option><option value="Lamar">Lamar</option><option value="Lauderdale">Lauderdale</option><option value="Lawrence">Lawrence</option><option value="Lee">Lee</option><option value="Limestone">Limestone</option><option value="Lowndes">Lowndes</option><option value="Macon">Macon</option><option value="Madison">Madison</option><option value="Marengo">Marengo</option><option value="Marion">Marion</option><option value="Marshall">Marshall</option><option value="Mobile">Mobile</option><option value="Monroe">Monroe</option><option value="Montgomery">Montgomery</option><option value="Morgan">Morgan</option><option value="Perry">Perry</option><option value="Pickens">Pickens</option><option value="Pike">Pike</option><option value="Randolph">Randolph</option><option value="Russell">Russell</option><option value="St. Clair">St. Clair</option><option value="Shelby">Shelby</option><option value="Sumter">Sumter</option><option value="Talladega">Talladega</option><option value="Tallapoosa">Tallapoosa</option><option value="Tuscaloosa">Tuscaloosa</option><option value="Walker">Walker</option><option value="Washington">Washington</option><option value="Wilcox">Wilcox</option><option value="Winston">Winston</option><option value=""></option></select></li><li class="er_fld_type_text er_fld_showif" draggable="false" er_fld_condfld="CST_69" er_fld_condvals="er_fld_showif_values=Alaska&er_fld_showif_values=Arizona&er_fld_showif_values=Arkansas&er_fld_showif_values=California&er_fld_showif_values=Colorado&er_fld_showif_values=Connecticut&er_fld_showif_values=Delaware&er_fld_showif_values=Florida&er_fld_showif_values=Georgia&er_fld_showif_values=Hawaii&er_fld_showif_values=Idaho&er_fld_showif_values=Illinois&er_fld_showif_values=Indiana&er_fld_showif_values=Iowa&er_fld_showif_values=Kansas&er_fld_showif_values=Kentucky&er_fld_showif_values=Louisiana&er_fld_showif_values=Maine&er_fld_showif_values=Maryland&er_fld_showif_values=Massachusetts&er_fld_showif_values=Michigan&er_fld_showif_values=Minnesota&er_fld_showif_values=Mississippi&er_fld_showif_values=Missouri&er_fld_showif_values=Montana&er_fld_showif_values=Nebraska&er_fld_showif_values=Nevada&er_fld_showif_values=New+Hampshire&er_fld_showif_values=New+Jersey&er_fld_showif_values=New+Mexico&er_fld_showif_values=New+York&er_fld_showif_values=North+Carolina&er_fld_showif_values=North+Dakota&er_fld_showif_values=Ohio&er_fld_showif_values=Oklahoma&er_fld_showif_values=Oregon&er_fld_showif_values=Pennsylvania&er_fld_showif_values=Rhode+Island&er_fld_showif_values=South+Carolina&er_fld_showif_values=South+Dakota&er_fld_showif_values=Tennessee&er_fld_showif_values=Texas&er_fld_showif_values=Utah&er_fld_showif_values=Vermont&er_fld_showif_values=Virginia&er_fld_showif_values=Washington&er_fld_showif_values=West+Virginia&er_fld_showif_values=Wisconsin&er_fld_showif_values=Wyoming" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Enter the name of the county that had your foster care case (if other state than AL)</label><input name="CST_71" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Name of last known/current worker</label><input name="CST_72" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Worker's Contact Number (if available)</label><input name="CST_73" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">What funds are you applying for:</label><select name="CST_74" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Fostering Hope">Fostering Hope</option><option value="ETV">ETV</option><option value="Both Fostering Hope & ETV">Both Fostering Hope & ETV</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Were you/will you be in foster care on your 18th birthday?</label><select name="CST_75" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_number er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_75" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">How old were you on the date of your adoption/permanent guardianship?</label><input name="CST_79" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 33.3333%;"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Were you or will you be in foster care at the time of your high school/GED graduation?</label><select name="CST_78" class="er_fld_required"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li><li class="er_fld_type_number er_fld_showif" draggable="false" er_fld_condfld="CST_78" er_fld_condvals="er_fld_showif_values=No" style="width: 33.3333%;"> <i class="fa fa-hashtag"></i><label class="er_fld_label required">How old were you on the date of your adoption/permanent guardianship?</label><input name="CST_80" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;" er_fld_condvals="er_fld_showif_values=No"><i class="fa fa-header"></i><label>Employment/Volunteer Status</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" er_fld_condvals="er_fld_showif_values=Yes" style="width: 50%;" map_to="CC_Employ_Status"><i class="fa fa-caret-down"></i><label class="er_fld_label required">What is your employment status?</label><select name="CST_83" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Part Time">Part Time</option><option value="Full time">Full time</option><option value="Part Time Volunteer">Part Time Volunteer</option><option value="Full Time Volunteer">Full Time Volunteer</option><option value="Not Employed">Not Employed</option><option value="Disability">Disability</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" map_to="CC_Employ_Employer" style="width: 25%;" er_fld_condfld="CST_83" er_fld_condvals="er_fld_showif_values=Part+Time&er_fld_showif_values=Full+time&er_fld_showif_values=Part+Time+Volunteer&er_fld_showif_values=Full+Time+Volunteer"> <i class="fa fa-font"></i><label class="er_fld_label required">Employer or Volunteer Agency</label><input name="CST_84" type="text" class="er_fld_required"></li><li class="er_fld_type_date er_fld_showif" draggable="false" style="width: 25%;" map_to="CC_Employ_Since" er_fld_condfld="CST_83" er_fld_condvals="er_fld_showif_values=Part+Time&er_fld_showif_values=Full+time&er_fld_showif_values=Part+Time+Volunteer&er_fld_showif_values=Full+Time+Volunteer"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Start Date of Employment/Volunteer Work</label><input class="cst_datepicker er_fld_required" name="CST_87" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" map_to="CC_Employ_Hours" er_fld_condfld="CST_83" er_fld_condvals="er_fld_showif_values=Part+Time&er_fld_showif_values=Full+time&er_fld_showif_values=Part+Time+Volunteer&er_fld_showif_values=Full+Time+Volunteer"> <i class="fa fa-font"></i><label class="er_fld_label required">Hours/Week</label><input name="CST_86" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">For students receiving Fostering Hope, the State of Alabama requires students to either volunteer 40 hours per semester OR work 5 hours per week to remain eligible to continue to receive Fostering Hope funds.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_dropdown" draggable="false" style="width: 50%;"><i class="fa fa-caret-down"></i><label class="er_fld_label">Is this your first application for Fostering Hope or ETV funding, regardless of the agency?</label><select name="CST_143"><option value="- Not Specified -">- Not Specified -</option><option value="Yes">Yes</option><option value="No">No</option></select></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_143" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Employer(s) from the last school year</label><input name="CST_145" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_143" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label">Average hours worked per week</label><input name="CST_148" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_143" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label">Volunteer/Service Agency(s)</label><input name="CST_146" type="text"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_143" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-font"></i><label class="er_fld_label">Number of volunteer hours for the last school year</label><input name="CST_147" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 100%;" er_fld_condfld="CST_143" er_fld_condvals="er_fld_showif_values=No"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Notes/Comments about volunteer hours or employment</label><textarea name="CST_149" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Budget Worksheet</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn er_fld_noprint">***Please enter all dollar amounts using whole numbers and round up to the nearest dollar. *** Please DO NOT uses $ symbols when entering amounts. Example: If you earned $201.12-Please enter this amount as 201</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>Student Budget</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">INCOME</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold"> INCOME TYPE</div></li><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold"> DOLLAR AMOUNT EARNED PER MONTH</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Wages/Compensation (Employment)</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required"></label><input name="CST_90" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_noprint er_fld_fontstyle_info">Examples of sources of "Other" income may include: Unemployment, Government Assistance (ex. food stamps/housing assistance), Alimony, Child Support, Monetary Gifts, Social Security Benefits (SSI, SSA, or SSDI) Military Benefits</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Other Income (if applicable)</label><input name="CST_92" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dollar Amount per Month</label><input name="CST_91" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Other Income (if appllicable)</label><input name="CST_93" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dollar Amount per Month</label><input name="CST_94" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Other Income (if applicable)</label><input name="CST_95" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"><i class="fa fa-font"></i><label class="er_fld_label">Dollar Amount per Month</label><input name="CST_96" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold"> TOTAL STUDENT INCOME</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_97" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label></label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">LIVING EXPENSES</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_noprint er_fld_fontstyle_info">Please enter 0 if an expense does NOT apply to you. Please DO NOT enter NA for any item</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold"> EXPENSE TYPE</div></li><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold"> COST PER MONTH (dollar amount)</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Rent</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_98" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Child Care</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_99" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Groceries</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"><i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_101" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Phone</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_102" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Cable/Internet</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_103" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Electric</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_104" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Natural Gas</div></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_105" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Water</div></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_106" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Dining Out/Movies/etc.</div></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_107" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Clothing</div></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_108" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Car Payment</div></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_109" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Auto Insurance</div></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_110" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Gasoline</div></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_111" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Auto Maintenance</div></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_112" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Transportation (uber, lift, public, taxi, etc.)</div></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_113" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Personal Care</div></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_114" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Health Insurance</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_115" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Other</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_117" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold"> TOTAL STUDENT EXPENSES</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_118" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 100%;"><i class="fa fa-header"></i><label></label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold">ANTICIPATED EDUCATION RELATED BUDGET</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 100%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn er_fld_noprint">***Please enter all dollar amounts using whole numbers and round up to the nearest dollar. *** Please DO NOT uses $ symbols when entering amounts. Example: If an expense cost you $201.12-Please enter this amount as 201</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">NOTE: If you do not know these costs, please estimate to the best of your ability. *We will confirm all information with your college/institution. Please enter 0 if an expense does NOT apply to you. Please DO NOT enter NA for any item You can leave this blank if you don't have enough information to complete this section.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold"> EDUCATION RELATED EXPENSES (payments directly to college/school/institution) </div></li><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold"> COST PER SEMESTER (dollar amount)</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Tuition and Fees</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_119" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Housing/Room & Board</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_120" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Meal Plan</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_121" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Books</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_122" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content"> Other</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_123" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_bold"> TOTAL EDUCATION RELATED EXPENSES</div></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label"></label><input name="CST_124" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label></label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label>RELEASE OF INFORMATION</label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Release of information/Authorization to recieve electronic communications.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">First Name</label><input name="CST_129" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Last Name</label><input name="CST_130" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info er_fld_noprint">Semester.Term Examples: Fall 2024; Spring 2024; 2024 Term 1; 2024 Term 2</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Current Semester/Term</label><input name="CST_131" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Student ID Number (as applicable)</label><input name="CST_133" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone Number</label><input name="CST_132" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Last 4 Digits of SSN or A-Number</label><input name="CST_134" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Name of College/Insitution</label><input name="CST_135" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 100%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Additional College/Institution (if taking classes at more than one college</label><input name="CST_150" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_section" draggable="false" style="width: 50%;"><i class="fa fa-header"></i><label></label><hr></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_warn">Authorization and Release of Information: I hereby authorize Embrace Alabama Kids to receive and release information as is pertains to my financial aid status, grades, enrollment status, academic status, progress, graduation information or other information required to determine my on-going eligibility for Education and Training Vouchers (ETV fund) and or the Fostering Hope Scholarship as well as other scholarships Embrace AL Kids may be administering. I understand that all information will be treated as confidential and privileged and used only for the purpose of monitoring my eligibility to receive ETV and or Fostering Hope funds by the entity indicated above. Your rights, as a client, with respect to this authorization: 1. Inspect or copy the information to be used or disclosed 2. Receive a copy of this information 3. Refuse to sign this authorization 4. Withdraw this authorization after it’s signed. You may give written notice to your EAK/UMCH worker to withdraw your authorization. Withdrawals of this authorization will be effective the date EAK/UMCH receives written notification of your intent to withdraw. </div></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Release of Information Timeframe</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_136" value="I understand that this authorization is in effect as of the signature date on this document and is valid for one year.">I understand that this authorization is in effect as of the signature date on this document and is valid for one year.</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_136" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_136_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Verification</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_137" value="I attest that the information I have provided is true and correct.">I attest that the information I have provided is true and correct.</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_137" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_137_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">Communication Consent</label> <label class="er_option"><input class="type_checkbox" type="checkbox" name="CST_138" value="I consent to receive communication via cell phone and email.">I consent to receive communication via cell phone and email.</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_138" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_138_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Do your best to caputure your signature using your mouse, finger, or stylus depending on the device you are using. If you cannot see a submit button under the signature field, please email s4s@emabracealkids.org for additional guidance.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 50%;"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Signature</label><input class="cst_datepicker er_fld_required" name="CST_140" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Enter content here...</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_signature" draggable="false" style="width: 50%;"> <i class="fa fa-pencil"></i><label class="er_fld_label required">Signature</label><div class="cst_signaturepad"></div><input name="CST_139" type="text" class="er_fld_required"><button class="type_button" disabled="">Clear Signature</button></li></ul>
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