SHC Referral Application

The following questions are used to determine your eligibility to apply for financial aid. Note that proof of residence and school enrollment may be required.
Do you live in the City of Richmond, Chesterfield County, or Henrico County?*

YesNo
Do you have any children under age 18 who are living with you now?*

YesNo
Are the children who are old enough to go to school, enrolled in school?*

YesNoNone of my children are old enough to go to school
Unfortunately, based on your responses above, you are not eligible to apply for financial aid.

Please do not complete this form. Select Cancel to see other options.
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Your name*

Given nameFamily name
Enter your phone number carefully. If your phone number is incorrect, we cannot process your application.
Do you have a U.S. mobile phone number?*

YesNo
Enter your U.S. mobile phone number beginning with the area code.*
Please enter a valid phone number.
Enter your mobile phone number beginning with the country code.*
Please enter a valid phone number.
Please enter your email address if you have one. If you include a valid email address you will receive a confirmation by email of your submission within a few minutes.
example@example.com
Thank you for providing an email address. For confirmation, please re-enter your email address.
example@example.com
The email addresses that you entered do not match. Please correct this problem before you continue.
Your Current Address*
Street address
Apartment or unit number
City*
State*
Zipcode*
Date of birth*

DayMonthYear
Enter the day first, the month second, and the year last
Country where you were born*
Enter the "A" number assigned to you by immigration officials. This number is written on most immigration notices or letters that have been provided to you. Sometimes it is called a Case Number or a File Number. If you leave this field blank, the processing of your application may be delayed. If you cannot find this number, ask a friend or relative to help you find it.
The date you (or the minor child in your care) last entered the U.S. If you don't know the exact date, enter an approximate date.*

Application for referral to legal counsel with financial aid.