About the Youth You are Referring

Please provide as much information about the youth you are referring to The Friendship Club as you can.  This will help us determine if they're a good fit for our program and services. Please know that everything you include on this form will be kept confidential.

Please note that although we accept referrals all year, our active recruitment period is from January-April for youth to start the summer after school ends. Referrals received after May 15th are often too late to be enrolled for that year as new youth start their journey with us in the summer. If you have any questions, please don't hesitate to contact our Associate Director, Dena Malakian, at (530) 265-4311 x204 or denav@friendshipclub.org.

Thank you for taking the time to complete this referral!

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* 1. Youth's First Name:

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* 2. Youth's Last Name:

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* 3. Youth's DOB:

Date

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* 4. Youth Biological Gender

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* 5. Youth Gender Identity

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* 6. Youth's Current School:

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* 7. Youth's Current Grade Level (Please note that if youth is referred during the summer, June 1-August 15, please indicate the grade they will enter in the new school year):

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* 8. If you know what school this youth will attend next school year, please write it below:

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* 9. What is the Parent's or Guardian's Name (first and last)?

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* 10. What is the relationship of this person to the youth?

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* 11. What is the parent/guardian mailing address?

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* 12. What is this parent's or guardian's phone number?

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* 13. Do you think this family will be able to pick their youth up once a week from meetings at TFC? Please note, TFC picks youth up from school and brings them to the club for their meetings after school.

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* 14. I have informed the parent/guardian that I am referring their child to the Friendship Club AND I have received verbal permission for TFC to interview this youth at their school site.

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