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Fill a Valid Georgia 57 Template

Name: Free Georgia 57 Form ⋆ PDF Template
Brand: Forms Georgia
Rating: 4.59091 (22 reviews)

The Georgia 57 form is a crucial document used in the child welfare system to facilitate child care referrals and applications for supplemental supervision. This form gathers essential information about foster children, their care providers, and the circumstances surrounding their placement. Proper completion of the Georgia 57 ensures that children receive the appropriate support and resources they need for their well-being.

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Contents

The Georgia 57 form plays a crucial role in the child welfare system, particularly for foster children in need of supplemental supervision. This form is essential for the Child Care Referral and Application process, which is managed by the Georgia Department of Human Resources. It gathers important information about the foster child, including their name, date of birth, ethnicity, and any disabilities they may have. Additionally, the form requires details about the foster care placement, such as the foster parent's contact information and the type of childcare provider selected—whether a relative or a non-relative. The form also outlines the specific needs for childcare, including days and hours required, and the start date for care. Eligibility determination is a key component, where the case manager assesses family unit size, costs, and whether the childcare provider meets the necessary licensing requirements. Timely updates regarding any changes in the child's placement or childcare arrangements must be communicated to the case manager to ensure compliance with regulations. Overall, the Georgia 57 form is a vital tool for ensuring that foster children receive the appropriate care and support they need during their time in the system.

Georgia 57 Example

Date Received by CAPS

Georgia Department of Human Resources

CHILD CARE REFERRAL & APPLICATION FOR SUPPLEMENTAL SUPERVISION

___________ County Department of Family and Children Services

A. FOSTER CHILD INFORMATION (To be completed by SSCM)

First Name MI Last Name Sex

Date	Social Security	Child	Child
of	Number	in	in
Birth		School	Pre-K

Child

Head

Start

Child has a disability

Ethnicity (check one):	Hispanic	Not Hispanic
Race (check one):	White	Black/African American	Asian
	American Indian or Alaskan Native		Native Hawaiian or other Pacific Islander

B. FOSTER CARE PLACEMENT INFORMATION (To be completed by SSCM)

Foster Parent's Name

Address

Home Phone

		Work Phone #

If an informal childcare provider has been chosen, check all that apply:
Relative of Child	Care provided in child's home	CRC completed
Non-Relative	Care provided in provider's home	CPS screening completed
		Approved by Foster Care

All changes in the child's placement and child care arrangements MUST be reported to the child care case manager within 5 working days.

____________________________________	________________	_______________
Signature of Foster Care Case Manager	Date	Case Load ID #

C. CHILD CARE PROVIDER INFORMATION (To be completed by the SSCM or Foster Parent)

Reason Care is Needed:

Days and Hours Care is Needed:

Date to begin CAPS: _____

Name, Address and Phone # of Childcare Provider:

Phone # :

D. ELIGIBILITY DETERMINATION (To be completed by the CAPS case manager)

1.	Family Unit Size	____		4.	Rate Within DFCS Maximum?		Yes	No
2.	UAS Code (check one):				Cost of care if not within maximum $_________
		555 (Pre-K)	557
3.	Provider is:			5.	Application Disposition:	Approved		Denied
	Licensed, Commissioned, or Exempt
	Registered			6.	Official Certification Period:
	Informal- Relative of Child				___________________ to __________________
	Informal- Non-Relative

Comments:

________________________________	_____________________	_____________________
Signature of CAPS Case Manager	Date	CAPS Case Load ID #

Form 57 (3/2004)

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Download Georgia 57

Document Breakdown

Fact Name	Details
Form Purpose	The Georgia 57 form is used for child care referral and application for supplemental supervision.
Governing Law	This form is governed by the Georgia Department of Human Services regulations related to child welfare.
Foster Child Information	Section A collects essential details about the foster child, including name, date of birth, and ethnicity.
Foster Care Placement	Section B requires information about the foster parent, including their contact details and approval status.
Child Care Provider	Section C gathers details about the child care provider, including their name, address, and reason for care.
Eligibility Determination	Section D assesses eligibility based on family size, UAS code, and provider status.
Application Disposition	The form includes a section for the case manager to indicate whether the application is approved or denied.
Submission Requirements	Changes in the child's placement must be reported to the case manager within five working days.

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