Community Care Services Referral

York IRC Mutual Aid Referral Form

Use this form to refer individuals for mutual aid and accompaniment.
*** Please Read Before Completing Referral Form***

You can use this form to refer someone to York Immigrant Rights Collective (York IRC) if they are a resident of York City or County, and if the individual or family has consented to have their information shared with the York IRC. Additional criteria must be met depending on the type of mutual aid that is being requested. The additional criteria by type of mutual aid are:

1. Assistance with Mutual Aid Team (referrals to existing medical and legal resources, limited financial support, ongoing food deliveries if needed, possible repatriation with country of origin if desired, and other forms of support): Must be an ICE-impacted family with children whose sole or primary breadwinner has been detained in the past few months.

2. Assistance with food pick-up and delivery and referrals to other existing resources that might be beneficial: Must be a family who is vulnerable due to local ICE activity and unable to access local resources.

3. Accompaniement to ICE check-in or ICE hearing: Must have a scheduled ICE check-in or ICE hearing.

Please note that due to limits on volunteer and financial resources, the York IRC cannot guarantee assistance, though every effort will be made to assist.
Did the community member/family you are referring, consent to this referral being made? *Please be sure to discuss this with the family to ensure a smooth transition to our IRC Mutual Aid Team.*
Full name of person making the referral
Referring person's telephone number
What is your relationship to the family or individual being referred?
Full name of community member being referred
What is the primary language of the community member being referred?
Has this community member had a loved one detained by ICE within the past 2 to 3 months?
If there has been an ICE detention of a loved one, what is the FULL NAME of the person detained?
Briefly describe the relationship of the community member and the detained loved one (i.e. spouse, parent, caregiver, etc):
Date of detention
Phone number of community member being referred
Community member address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list age, gender, and schools enrolled in for all children in the family. Example: 8 yo male - Lincolnway Elementary; 15 yo female William Penn HS
Please indicate which forms of mutual aid this community member is seeking (Check all that apply).
Is there any other information you would like us to know about your situation?
Type a question
Should be Empty:

York IRC Mutual Aid Referral Form