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Direct Services
Parent/Caregiver First Name
*
Parent/Caregiver Last Name
*
Primary Email
*
Primary Phone Number
*
Enter International
Number of Legal Guardianship Children in Home
Number of Adoptive Children in Home
Number of Foster Children in Home
FAC Location
*
Cape Girardeau, MO
Chillicothe, MO
Independence, MO (HQ)
Kansas City, KS
Poplar Bluff, MO
Springfield, MO
Would you be interested in immunizations if available?
Yes
No
Back to School Children
This section below must be filled out. Please select the number of children needing backpacks using the drop down list. **If your child is in kindergarten select 0 for grade.
Back to School
0
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Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
Child First Name
*
Child Last Name
*
Child's Date of Birth
*
Child's Gender
*
Agender
Female
Gender Fluid
Gender Queer
Male
Nonbinary
Transgender, female
Transgender, male
Two Spirit
Prefer Not to Answer
Questioning
Child's Grade
*
Child's School
Child Type
Adopted
Foster Care
Relative/Kinship
YCC Youth
Is this child getting a haircut at the event?
Yes
No
Child's Race & Ethnicity
*
African
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Multiracial
Native Hawaiian or Other Pacific Islander
Other
White or Caucasian
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