Growing Community Connections (GCC)

Family Coaching Application

If you have any questions or need assistance completing this application, please contact our Central Navigator, Sandy Nation at 712-389-4401 or snation@siouxlandship.org.

For Spanish, please contact our Lead Coach, Karen Ramos, 712-535-9096 or kramos@siouxlandship.org.

Eligibility Requirements:

Central Navigation:

Dakota County Nebraska Resident
Willingness to engage in the support and resources offered

Family Coaching:

Dakota County Nebraska Resident
Must be a parent or a minor child aged eighteen or younger, or eighteen and high school, a non-custodial parent of a minor child or a pregnant parent in their household.
Parent/Caregiver or child(ren) USA Citizen/Legal Resident
Income at or below 200% of the Federal Poverty Level (FPL)
Willingness to engage in the support and resources offered

Plans of Safe Care:

Dakota County Nebraska Resident
Families with children at risk due to parental substance use
Willingness to engage in the support and resources offered

Connected Youth Initiative:

Nebraska Resident
Be between the ages of 14 and 26
Be living without family support
Willingness to engage in the support and resources offered

Tell us About yourself...

First name

Last name

Birthday

Month

Day

Year

Address

County

Please upload a copy of a bill for proof of Dakota County, NE residency. Include a bill that has your first and last name and physical address. (Utility bill, medical bill, phone bill, etc.)

File upload

Phone

Alternative Contact Information (If applicable)

What is your primary language?

Other Language if not listed

What is your marital status?

Gender Identity - Do you currently describe yourself as:

Man

Woman

Prefer not to say

Prefer to self identify

Are you currently of have you every experienced any of the following?

What is your current employment status? (Check all that apply)

What is your residential status?

We take your privacy seriously. The information you provide regarding your residential status will be used solely to determine your eligibility for specific programs and services based on available funding.

Please upload proof of your residential status (if applicable): (Valid Drivers License, Valid State ID, Social Security Card, Passport, Green Card)

File upload

What is the highest degree or level of school you have completed?

Are you interested in continuing your education?

Yes

Not at this time

Do you have a disability?

Yes

Prefer not to say

Are you currently pregnant or expecting a child (mother or father)?

Yes

Prefer not to say

Tell us about your household...

Including yourself, how many adults are in your household?

How many children (18 and under) are in your household? Enter 0 if no children live with you

Please list all adults living in the home, date of birth, and how they are related to you. (if applicable)

Please list all children (18 and under) living in the home, date of birth, and how they are related to you.

Do any of your children have a disability?

Yes

Prefer not to say

If you have any children with a disability, are they receiving services?

Yes

Not sure

Prefer not to say

Children's residential status?

Please upload child(ren) proof of residential status (if applicable): (Valid Drivers License, Valid State ID, Social Security Card, Passport, Green Card)

File upload

Please upload all documents to prove earned income: Verification of income may include the following:

Paystubs (12 months)
Employer Statement
Income Tax Return (Form 1040, W-2 Forms, Form 1099)
Self - Employment Ledgers
Unemployment Compensation award letter
Worker's Compensation award notice
Alimony or Child Support
Social Security Statements
Verification of public benefits; or,
Other Income Verifications (Pension or Retirement, Self-Disclosure of No Income, Lottery Winnings,

File upload

Current Services and Supports

How can we help?

Please include any additional information you feel we will need in order to process your application.

By typing my name, I certify all information is true and correct to the best of my knowledge.

First and Last Name

Authorization to Share Your Information for Evaluation (Consent)

We would like to share some of your information with the Nebraska Children and Families Foundation Research and Evaluation team and their external partners. They aim to understand and improve how Growing Community Connections supports families. Your name, address, and other identifying information will NOT be shared. Only details about the services you received and their impact will be included. You may also be contacted for feedback about your experience.

Do you give permission for us to share this information with them?

Yes

Once submitted, a member of our team will reach out to you with additional information about the next steps towards receiving support services.

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