Young Adult Voluntary Foster Care Verification of Eligibility	Youth Name:
MDHHS Office:
Michigan Department of Health and Human Services	Worker Name:
INSTRUCTIONS
To be completed by an employer, volunteer coordinator, school personnel, or medical professional with knowledge of the above-referenced youth’s participation with your business/organization. Please complete the appropriate section and provide your information/signature on the second page. This form is used to document initial and ongoing program eligibility but is not required if other documents are being submitted that verify eligibility, such as pay stubs. This form can be used to document one type of eligibility. If youth is required to show two types, such as both education and employment, then a MDHHS-5778 needs to be completed for each.
EMPLOYMENT: Employer, please provide the information requested in the section below for the above-named employee. You are hereby authorized to release the information requested below to the Michigan Department of Health and Human Services.
Employee Name	Employee Signature
Employer Name	Occupation
Date Employment Began	Date of First Paycheck	Number of Hours Expected to Work
Per Week	Per Pay Period
If already working, number of hours completed in the last three calendar months
Month	Total Hours	Month	Total Hours	Month	Total Hours
Is the employee expected to work at least 80 hours per month?	Yes	No
HIGH SCHOOL/GED COMPLETION EDUCATION: School official, please provide the information requested below for the above-named student. You are hereby authorized to release the information requested below to the Michigan Department of Health and Human Services.
Student Name	Student Signature
Name of School	Type of School
High School	GED preparation
Is student actively working toward a diploma or GED?	Date Started to Attend
Yes	No
POST-SECONDARY/VOCATIONAL TRADE OR TECHNICAL TRAINING: School official, please provide the information requested below for the above-named student. You are hereby authorized to release the information requested below to the Michigan Department of Health and Human Services.
Student Name	Student Signature

Name of School	Type of School
Post-Secondary
Vocational Trade or Technical Training
Enrollment Date	Enrollment Status
Full-Time Student	Half-Time Student
Less Than Half-Time	Not Enrolled
VOLUNTEER WORK: Community Organization Official, please provide the information requested below for the above-named volunteer. You are hereby authorized to release the information requested below to the Michigan Department of Health and Human Services.
Volunteer Name	Volunteer Signature
Community Organization Name	Volunteer Activity
Date Volunteer Activity Began	Number of Hours Expected to Volunteer per Month
Month	Total Hours	Month	Total Hours	Month	Total Hours
MEDICAL NEEDS: Medical Professional, please provide the information requested below for the above-named patient. You are hereby authorized to release the information requested below to the Michigan Department of Health and Human Services.
Patient or Representative’s Name	Patient or Representative’s Signature
Diagnosis(es)
Date of Diagnosis	Is the patient unable to work, volunteer or attend school at least part time?
Yes	No
How long is this condition expected to last?	When can patient return to work?
SIGNATURE/CONTACT INFORMATION FOR OFFICIAL COMPLETING FORM
Business/Organization/School/Medical Practice Name
Name	Title	Phone Number
Address	City	State	Zip Code
Signature	Date
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.