Agency/Individual Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Level of Participation

Participation as an Organizational Member: Agencies or entities that have DCYF child welfare serving contracts including in-home services, child placing agencies and behavioral rehabilitation services. (This excludes agencies who primarily serve early learning- see supporting organization). Participation as a Partnering Organization: Agencies or entities whose primary focus is legislative, administrative, and/or local advocacy on behalf of children and families. Participation as a Supporting Organization: Agencies that support families involved with or at risk of involvement with the child welfare system, whose primary sources of funding are not through DCYF contracts. Choose one:

Participation as an Organizational Member

Participation as a Partnering Organization

Participation as a Supporting Organization

Main Contact Person/CEO/ED:Main Contact Person/CEO/ED:

First Name

Last Name

Phone

(###)

###

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WACF is composed of four divisions: Choose one or more (if applicable) and enter the required information. If you are a Supporting Organization this does not apply. Please skip to the Form Submitter section below.

The Child Placing Agencies (CPA) Division, is composed of private, community based foster care agencies that recruit, license, train and support foster families. Child Placing Agencies work collaboratively with DCYF to ensure timely permanency. The Intensive Services Division, is composed of agencies that provide Behavioral Rehabilitation Services, Crisis Residential Centers, HOPE beds, Regional Assessment Centers, therapeutic foster care and other services designed to serve children, youth, and their families with multidimensional and complex needs. The Family Preservation and Support Services (FPSS) Division, is composed of agencies that provide in-home and community-based services to families, with the goal of stabilizing families to prevent children from entering more intensive services, including out-of-home care. The Independent Living (IL) Division, is composed of agencies that provide services designed to assist youth and young adults ages 15 - 23 in making the transition from foster care to self-sufficiency.

Child Placing Agencies

Intensive Services

Family Preservation & Support Services

Independent Living

Your Name

First Name

Last Name