About the Student You are Referring

Please provide all pertinent contact and background information about the student you are referring to the SAFE program for youth experiencing homelessness. For now, we are only accepting referrals for current high school juniors who are homeless under the McKinney-Vento Act definitions. We will use the information you provide to help us serve the student as best as we can. Please know that everything you include on this form will be kept confidential.

If you have any questions, please don't hesitate to contact our Youth Empowerment Coordinator, Aurora Packard, at (530) 265-4311 x208 or aurorap@friendshipclub.org.

Thank you for taking the time to complete this referral!

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* 1. Student's First Name:

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* 2. Student's Last Name:

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* 3. Student's DOB:

Date of Birth:

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* 4. What gender does this student identify with?

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* 5. Student's Current School:

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* 6. Student's Current Grade Level:

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