Program Referral Form

Program Referral Form
Date*

MonthDayYear
Date
Referral Source Name*

First NameLast Name
Referral Source Agency*

Cecil County Public SchoolsLocal Care TeamDepartment of Social ServicesDepartment of Juvenile ServicesSelf-ReferralOther
Referral Source Email*
example@example.com
Referral Source Phone Number*
Please enter a valid phone number.
Has the legal guardian been made aware of the referral to Youth Empowerment Source:*

YesNo
Program Selection (check one)*

Children of Incarcerated Parents supports youth ages 5-17 who have a parent/guardian actively incarcerated or who has been incarcerated within the last 24 months.Stride is an intervention program designed to assist youth ages 8-18 who are facing adversityThe Legacy Program assists youth between the ages of 16-24 who have not graduated high school and are struggling to find/sustain employment.
Youth’s Relationship to Incarcerated Individual:*
Check all that apply:*

RunawayFamily Issues/ConflictTruancy/School IssuesBehavioral IssuesSubstance Abuse
Choose the option which best applies*

Youth is still enrolled in schoolYouth is not enrolled in school
Date student was withdrawn from school*

MonthDayYear
Date
Youth's Full Name*

First NameLast Name
Youth's Date of Birth*

MonthDayYear
Date
Youth's Age*
Youth's Race*
Youth's Gender*
School*
Current Grade or Last Grade Completed*
Legal Guardian's Full Name*

First NameLast Name
Relationship to Youth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Additional Contact Information
Additional Information
If you are referring more than one child or sibling, please complete a separate referral form for each individual.
Should be Empty:

Program Referral Form

If you are referring more than one child or sibling, please complete a separate referral form for each individual.