R.E.A.D. Referral Form

Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PARENT/GUARDIAN
Parent/Guardian's Email
example@example.com
Child's Name

CHILD'S FIRST NAMECHILD'S LAST NAME
Address

Street Address

Street Address Line 2

CityState

Zip Code
HOME PHONE

Area CodePhone Number
CELL PHONE

Area CodePhone Number
CHILD'S GRADE
CHILD'S SEX
CHILD'S RACE
Reason For Referral - Check all that apply

Other
Child's Shirt Size
Child's Pants Size
Child's Dress Size
Child's Shoe Size
I, the parent or guardian of the above listed child, agree to my child participating in the Role Model R.E.A.D. Program. Parent/Guardian Signature
Should be Empty: