This form must be completed and submitted to Medi-Cal to ensure that all emancipated foster youth receive the free Medi-Cal coverage from age 18-21 to which they are entitled. Check with the child's social

worker to see if he or she has already submitted this form. If the child does not have an after-care address to provide, check with Don Graves at ILSP (he allows the youth to use the ILSP office as their

after-care address because ISLP continues to work with the youth through age 21).