Peers Paving the Path Interest Form

YOUTH APPLICANT INFORMATION

First Name

Last Name

Are you preparing to age out of care or have already aged out?

YesNo

Phone Number

County of Jurisdiction (where your CPS case is located).

Caregiver or Supportive Adult First Name

Caregiver or Supportive Adult Last Name

Do you know what kind of insurance you have?

YesNo

If you know what Managed Care Provider (MCP) you have under Medi-Cal, please list it. If you don't know your insurance provider, please mark "I Don't Know".

If your Managed Care Provider (MCP) was not listed above, please enter your insurance provider. If your insurance provider was listed, please leave this question blank. NOTE: MediCal is not a Managed Care Provider.

California Benefits Card Example of where to find your CIN number:

Please Enter your CIN Number:

If You are an Agency or Caregiver Completing the Referral

Relationship to the Child/Youth

Phone

Referring Agency (if one)

Questions?? - call, email or text us and one of our team members will be in touch asap:
Phone or Text: 213-459-1128 or 530-550-8001
Email: TAYAmeriCorps@iFoster.org

Contact Information