Project Dream Dress Foster Parent and Case Manager Referral Form

Please fill the form out with the student. Referral information will be used only for scheduling purposes, and demographic information will remain private.

By checking this box, the student understands this information will be shared with the Foster & Adoptive Care Coalition.

Your Information

Name of Individual Submitting this referral

Relationship to Student

Student Information

Student's First Name

Student's Last Name

Student's Gender Identity

Other Gender Identity (please specify)

Student's pronouns, select all that apply (Hold down CTRL to select multiple)

Other pronouns

Student's Racial Identity

Other Racial Identity (please specify)

Student's Legal Status

Student's Cell Phone

Email Address Student Checks Regularly

Name of High School

Grade

Date of Prom

Adult Contact Information

Case Manager Name

Case Manager Cell Phone

Case Manager Email

Caregiver Name

Caregiver Phone

Caregiver Email

Appointment Information

Who will bring the student to the appointment?

What is the best email or phone for the person bringing the student?

Estimated Dress Size

Shopping days will be from Friday March 1st to Saturday March 9th. Please choose 3 preferred appointment times. Our Family Enrichment Manager will contact you with your assigned appointment time!

Preferred Appointment Times (Hold down CTRL and Choose 3 please)

The Dress Boutique is located at ReFresh 1710 S. Brentwood Blvd., St. Louis MO 63144

Visit our website at http://www.foster-adopt.org/cinderallaproject for more information.

For more information, contact Madison Brown, Family Enrichment and Volunteer Manager at 314.806.2556 or madisonbrown@foster-adopt.org