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I have read the guidelines and steps for making a referral
Referring Party Information
Date
Full Name
Relationship to Child
Cell Phone
Work Phone
Email
Address
City
Zip
Recipient's Information
Full name of child
Age
School
School District
County
Request
Information
Has this child been referred before?
If yes, what was the referral number?
Dollar amount requested
How will these funds be used?
How many children will benefit from this request?
PLEASE NOTE! Failure to fill out this section with sufficient information will result in your referral being denied and the need for your request to be resubmitted. Please describe IN AS MUCH DETAIL AS POSSIBLE how the child has been impacted by crime, abuse and/or neglect.
Submit
Thank you for your referral!
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