Refer A Child - Information Form

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Newsletter - Fall 2008

Client Referral / Information Form

Client Information:

* Indicates Required Field

*Client's First Name
*Client's Last Name
*Date of Birth	(mm/dd/yyyy)
*Parent/Guardian Name
*Address 1
Address 2
*City
*State
*Zip Code
*Phone

Referred By:

First Name
Last Name
Date	(mm/dd/yyy)
Relationship
Organization
Address 1
Address 2
City
State
Zip Code
Phone
Email

Previous involvement with Parent Plus?

Yes
No
If Yes, When?

Financial Information:

1. Are you in any of the following programs? (Check all the apply)

Medicaid (Title XIX/Medical, State Supplemental Assistance):
Food Stamps:
Supplemental Security Income (SSI):
Federal Public Housing Assistance:
Temporary Assistance to Needy Families Program:
National School Lunch Program (NSL):
None of the above programs:

*2. What is your annual income?

References / Verification:

Obituary Death Certificate Other Specify

For verification purposes, please provide the name and phone number of one or two other people who are familiar with the situation or provide other similar documentation.

First Name
Last Name
Phone
First Name
Last Name
Phone

Client's Strengths / Interests:

1. What are the child's strengths, hobbies and / or things they are interested in?

2. Has the child previously been involved in any activities or programs?

3. Do you have a specific program in mind?

Please describe the situation; include as many details as possible. Feel free to attach any additional supporting document files in the space provided. THANK YOU!

Your Information:

*First Name
*Last Name
*Phone
*Email
*Confirm Email

* I understand completion of this certification form does not constitute immediate acceptance into a program. I agree to notify Parent Plus, Inc. if I cease to participate in any of the public assistance programs I checked above.

By selecting "Send", I certify the above information is true. I have read the information on this certification form and understand that I must meet the above qualifications to receive assistance for any programs.

Please enter the number shown and Click "Send": 60358

"Parent Plus is a non-profit organization assisting families who are coping with loss, death, or illness. We strive to build life long relationships with sports, arts, and academics and increase community awareness, mentoring and coaching profieciency."