Program Referral Form
Date
*
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Month
-
Day
Year
Date
Referral Source Name
*
First Name
Last Name
Referral Source Agency
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Cecil County Public Schools
Local Care Team
Department of Social Services
Department of Juvenile Services
Self-Referral
Other
Referral Source Email
*
example@example.com
Referral Source Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Has the legal guardian been made aware of the referral to Youth Empowerment Source:
*
Yes
No
Program Selection (check one)
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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 adversity
The 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:
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Check all that apply:
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Runaway
Family Issues/Conflict
Truancy/School Issues
Behavioral Issues
Substance Abuse
Choose the option which best applies
*
Youth is still enrolled in school
Youth is not enrolled in school
Date student was withdrawn from school
*
-
Month
-
Day
Year
Date
Youth's Full Name
*
First Name
Last Name
Youth's Date of Birth
*
-
Month
-
Day
Year
Date
Youth's Age
*
Youth's Race
*
Please Select
African American/Black
Asian or Pacific Islander
Hispanic/Latino
Middle Eastern/North African
Multi-Racial
White
Unknown/Prefer not to respond
Youth's Gender
*
Please Select
Male
Female
Non-Binary
Unknown/Prefer not to respond
School
*
Current Grade or Last Grade Completed
*
Legal Guardian's Full Name
*
First Name
Last Name
Relationship to Youth
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Contact Information
Additional Information
If you are referring more than one child or sibling, please complete a separate referral form for each individual.
Submit
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