Adoption, Foster, Kinship Connections Support Group Report and Payment Request Form

Full Legal Name*

First Last

Email*

Do you have a new street address?*

If this is your first time completing this form, please choose "yes" so we have your street address to mail your stipend to.

Yes
No

Address*

Street Address City State ZIP Code

Cell Phone*

Number of meetings for payment or reporting (up to 4)*

Please note, additional fields to complete will appear based on the number entered.

Please enter a number from 1 to 4.

Date of Meeting 1*

mm/dd/yy

Time of Meeting 1*

ie: 6:30 PM to 8:30 PM

Name of Group 1*

Location of Meeting 1*

Role for Meeting 1*

What was your role in the meeting?

Support Group Leader
Child Care

Number of Adult Attendees*

If no adult attendees, enter 0. Please do NOT count facilitators.

Number of Child or Youth Attendees*

If no child or youth attendees, enter 0

Meeting 1 Attendee List*

How are you providing the attendee list?

Typing or pasting attendees in text boxes below
I want to upload a pdf of attendees

Meeting 1 List of Adult Attendees*

Meeting 1 List of Children or Youth Attendees*

Meeting 1 Attendee List Upload*

Upload a pdf of the list of attendees from this meeting. Separate the adult and child/youth attendees as 2 different lists on the page.

Accepted file types: jpg, pdf, png, Max. file size: 1 MB.

Name of Group Facilitator*

Date of Meeting 2*

mm/dd/yy

Time of Meeting 2*

Name of Group 2*

Location of Meeting 2*

Role for Meeting 2*

Support Group Leader
Child Care

Number of Adult Attendees Meeting 2*

If no adult attendees, enter 0. Please do NOT count facilitators.

Number of Child or Youth Attendees Meeting 2*

If no child or youth attendees, enter 0

Meeting 2 Attendee List*

How are you providing the attendee list?

Typing or pasting attendees in text boxes below
I want to upload a pdf of attendees

Meeting 2 List of Adult Attendees*

Meeting 2 List of Children or Youth Attendees*

Meeting 2 Attendee List Upload*

Upload a pdf of the list of attendees from this meeting. Separate the adult and child/youth attendees as 2 different lists on the page.

Accepted file types: jpg, pdf, png, Max. file size: 1 MB.

Name of Group Facilitator Meeting 2*

Date of Meeting 3*

mm/dd/yy

Time of Meeting 3*

Name of Group 3*

Location of Meeting 3*

Role for Meeting 3*

Support Group Leader
Child Care

Number of Adult Attendees Meeting 3*

If no adult attendees, enter 0. Please do NOT count facilitators.

Number of Child or Youth Attendees Meeting 3*

Meeting 3 Attendee List*

How are you providing the attendee list?

Typing or pasting attendees in text boxes below
I want to upload a pdf of attendees

Meeting 3 List of Adult Attendees*

Meeting 3 List of Children or Youth Attendees*

Meeting 3 Attendee List Upload*

Upload a pdf of the list of attendees from this meeting. Separate the adult and child/youth attendees as 2 different lists on the page.

Accepted file types: jpg, pdf, png, Max. file size: 1 MB.

Name of Group Facilitator Meeting 3*

Date of Meeting 4*

mm/dd/yy

Time of Meeting 4*

Name of Group 4*

Location of Meeting 4*

Role for Meeting 4*

Support Group Leader
Child Care

Number of Adult Attendees Meeting 4*

If no adult attendees, enter 0. Please do NOT count facilitators.

Number of Child or Youth Attendees Meeting 4*

Meeting 4 Attendee List*

How are you providing the attendee list?

Typing or pasting attendees in text boxes below
I want to upload a pdf of attendees

Meeting 4 List of Adult Attendees*

Meeting 4 List of Children or Youth Attendees*

Meeting 4 Attendee List Upload*

Upload a pdf of the list of attendees from this meeting. Separate the adult and child/youth attendees as 2 different lists on the page.

Accepted file types: jpg, pdf, png, Max. file size: 1 MB.

Name of Group Facilitator Meeting 4*

Anything else you would like us to know?

Please Note

If you are not re-directed to a different web page after you click on the submit button, you have NOT successfully submitted. Scroll through the page and determine what information is missing and re-enter and submit.

You will receive an email confirmation right away.

If you have any questions, please contact Nick at nickschanilec@nacac.org.

Email

This field is for validation purposes and should be left unchanged.

Adoption, Foster, Kinship Connections Support Group Report and Payment Request Form

Group Report and Stipend Request

Please Note