Step Forward with Confidence

Request Form

Second Families is dedicated to supporting Afghan women with:
✅ Early Childhood Development For Afghan Women (Mothers)
✅ Parental Education & Stabilization For Afghan Women (Mothers)
✅ Driving Courses & Sessions
✅ ESL (English as a Second Language) For Afghan Women (Mothers)
✅ Career Path Guidance & Employment Services
✅ Sports Activities for Youth

Todays Date *

Are you new to this program? *YesNo

Have you Signed Authorization of Release of Information Form *Participant or Parent SignedYesNo

Do you agree to provide photo release form? *YesNo

Did your family arrive in the U.S. after July 31st, 2021? *YesNo

First Name *

Last Name *

Age *

Date of Birth *

Preferred Language *

Other language

Gender *

Other

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone Number *

Spouse first name

Spouse last name

Spouse Alien ID #Please enter a six- to nine-digit, or fifteen-digit number without any hyphens or spaces between the numbers. Do not enter an “A” at the beginning of the number.

Alien ID #Please enter a six- to nine-digit, or fifteen-digit number without any hyphens or spaces between the numbers. Do not enter an “A” at the beginning of the number.

Entry date to the U.S *

Eligibility Documentation *“AHP” for Afghan Humanitarian Parolees; “ASY” for Asylee; “REF” for Refugee; “SIV” for Special Immigrant Visa holder; “VOT” for Victim of Trafficking.

Did you move from another State, if "Yes"? Then enter Date(mm/dd/yyyy)

Did the participant/youth migrate from another U.S. state? *YesNo

Number of Children under 18 years old? *

Number of Children under 5 years old? *

Child 1 First Name

Child 1 Last Name

Child 1 Date of Birth

Child 1 Age

Child 1 GenderMaleFemale

Child 1 Grade Level

Child 1 Alien Number, Green Card, Work Permit

Child 1 Date of Entry to U.S

Child 2 First Name

Child 2 Last Name

Child 2 Date of Birth

Child 2 Age

Child 2 GenderMaleFemale

Child 2 Grade Level

Child 2 Alien Number, Green Card, Work Permit

Child 2 Date of Entry to U.S

Child 3 First Name

Child 3 Last Name

Child 3 Date of Birth

Child 3 Age

Child 3 GenderMaleFemale

Child 3 Grade Level

Child 3 Alien Number, Green Card, Work Permit

Child 3 Date of Entry to U.S

Child 4 First Name

Child 4 Last Name

Child 4 Date of Birth

Child 4 Age

Child 4 GenderMaleFemale

Child 4 Grade Level

Child 4 Alien Number, Green Card, Work Permit

Child 4 Date of Entry to U.S

Child 5 First Name

Child 5 Last Name

Child 5 Date of Birth

Child 5 Age

Child 5 GenderMaleFemale

Child 5 Grade Level

Child 5 Alien Number, Green Card, Work Permit

Child 5 Date of Entry to U.S

Staff First NamePlease ONLY complete this section after reviewing the eligibility documentation for ALL participants listed above.

Staff Last NamePlease ONLY complete this section after reviewing the eligibility documentation for ALL participants listed above.

Confirmation of Participant Eligibility Documentation and Consent- Date Eligibility Verification Completed

Please select which of the following types of eligibility documents you have reviewed to confirm participants' eligibility status

Based on your review of this information, please indicate type of document(s) kept on fileHard CopyElectronic Copy

Based on your review of this information, is this participant/family eligible for ARSI services?Yes, I confirm this family IS eligible for ARSI/AYM servicesNo, this family is NOT eligible for ARSI/AYM services