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Referring Party Information
Date
*
Month
Full Name
*
Relationship to Child/Place of work
*
Cell Phone
*
Work Phone
*
Email
*
Address
*
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?
*
Failure to fill out this section with sufficient information will result in your referral being denied & 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/neglect.
*
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