Care History Summary Statement Request Form

I would like to apply for my Care History Summary Statement. This will assist me to register with the Forde Foundation and to access other services and resources available to care leavers.

Care History Summary Statement Request Form

Upon submitting this form, please send an email to fordefoundation@csyw.qld.gov.au with certified proof of identification (e.g., a certified copy of your driver’s licence, passport, birth certificate or prisoner’s identity card certified by a Corrective Services Officer) to validate your submitted Care History Summary Request form.

Title
First Name*
Surname*
Date of Birth*
Gender
Address*
Suburb*
State
Postcode*
Email Address
Phone Number*
Other Names Used In Care (if applicable)
Names Of Institutions (if applicable)
Years In Care (if known)
Other Relevant Information
eg. Mother's maiden name, Names of brothers and/or sisters, Name of foster family
Declaration*
- This Agreement may be executed and delivered by electronic means and upon such delivery the electronic signature will be deemed to have the same effect as if the original signature had been delivered to the other party.
Upon submitting this form, please send an email to fordefoundation@csyw.qld.gov.au with a copy of your identification (e.g. licence, birth certificate) which has been signed by a Justice of the Peace, Commissioner of Declarations or a Corrective Services Officer to validate your submitted Care History Summary Request form.
Comments
This field is for validation purposes and should be left unchanged.

Privacy Notice

The Forde Foundation is collecting your personal information for the purposes of assisting you obtain your care history summary statement from the Department of Child Safety, Youth and Women to enable you to register with the Forde Foundation and access resources available to care leavers.