KY-KIN Peer Support Participant Registration Form Caregiver Name* First Last Date Date Format: MM slash DD slash YYYY Home Address* Street Address APT/Box City State ZIP / Postal Code Phone*Preferred Email* County of residence?*AdairAllenAndersonBallardBarrenBathBellBooneBourbonBoydBoyleBrackenBreathittBreckinridgeBullittButlerCaldwellCallowayCampbellCarlisleCarrollCarterCaseyChristianClarkClayClintonCrittendenCumberlandDaviessEdmonsonElliottEstillFayetteFlemingFloydFranklinFultonGallatinGarrardGrantGravesGraysonGreenGreenupHancockHardinHarlanHarrisonHartHendersonHenryHickmanHopkinsJacksonJeffersonJessamineJohnsonKentonKnottKnoxLarueLaurelLawrenceLeeLeslieLetcherLewisLincolnLivingstonLoganLyonMcCrackenMcCrearyMcLeanMadisonMagoffinMarionMarshallMartinMasonMeadeMenifeeMercerMetcalfeMonroeMontgomeryMorganMuhlenbergNelsonNicholasOhioOldhamOwenOwsleyPendletonPerryPikePowellPulaskiRobertsonRockcastleRowanRussellScottShelbySimpsonSpencerTaylorToddTriggTrimbleUnionWarrenWashingtonWayneWebsterWhitleyWolfeWoodfordSo that we can best match you with support services, please tell us a little about yourself.What is your age?*How do you describe your gender?*Which of the following BEST describes you?*SelectRelative CaregiverFictive Kin CaregiverChild-Specific Foster Care Relative Care ProviderOther (Please specify below)What best describes you?Which of the following BEST describes how your fictive kin/relative came to be placed with you?*SelectFormal Arrangement (The child(ren) was placed with me by CPS)Informal (The child(ren) was NOT placed with me by CPS)Relative/Fictive Child(ren) Information:Please provide the names/ages of the relatives/fictive kin currently in your care.*NameAgeRelationship of the child(ren) to you Click the + at the end of the row to add up to four more children.In total, how long have you been caring for the relative/fictive kin child(ren) in your home. To answer this question, please think about the child(ren) you have had the LONGEST?*Community Agency InvolvementDo the child(ren) in your care currently have an OPEN DCBS case?*SelectYesNoWho is the DCBS worker?*Request for ServicesKY-KINS Peer Support program provides a personal, one on one, mentoring services to assist Relative/Fictive Kin caregivers in providing the best care for the children they are raising at no cost. Through these services, Caregivers will have frequent contacts with their Peer Supporter each week designed to help Caregivers navigate resources, network with needed professionals and services, and receive support designed to aid the Caregiver in providing a stable home for relative/fictive kin children. Please indicate any specific requests or areas you would like assistance from a Peer Supporter, if anyWhat are you hoping this program can provide for you and your family?*By submitting this form electronically, you are electing to participant in the KY-KINS Peer Support Program.What happens next?A KY-KINS staff member will reach out to you within the next five days. In the meantime, if you have any questions, please feel free to contact Sheila Rentfrow or 859-257-4785.