About the Girl You are Referring

Please provide all pertinent contact and background information about the girl you are referring to The Friendship Club. We will use this to determine if she meets the initial criteria to receive our 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 girls to start the summer after school ends.  Referrals received after May 15th are often too late to be enrolled for that year as new girls start their journey with us in the summer. If you have any questions, please don't hesitate to contact our Associate Director, Dena Valin, at (530) 265-4311 or denav@friendshipclub.org.

Thank you for taking the time to complete this referral!

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* 1. Girl's First Name:

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* 2. Girl's Last Name:

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* 3. Girl's DOB:

Date of Birth:

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* 4. Girl's Current School:

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* 5. Girl's Current Grade Level:

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

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* 7. What is the relationship of this person to the girl?

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

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

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

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

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