Children and families remain our top priority during the COVID-19 emergency. All referrals continue to be accepted and acted on during this time. The local school district will contact the family within 7-10 days with specific information and next steps. Thank you for your patience during this unprecedented time. Refer a Child.

Refer a Child: Form for Friends, Family Members and Others

If you are not the parent or guardian, you may make a referral without parent consent for children birth to kindergarten. We encourage you to speak with the family about this referral. The local infant and toddler intervention or preschool special education program will contact the family for their permission to proceed with the referral. Parents may accept or decline.

Starred (*) fields are required. You can also call 1-866-693-4769 to refer a child.

Child Information

Each child must be referred individually. You will be given the option to 'Refer another Child' when you complete this referral.

Child's First Name*

Child's Last Name*

Child's Middle Initial

Date of Birth

Child's Age*

Parent is Aware Of This Help Me Grow Referral *

YesNo

Child Resides With*

Parent(s)

Other Family (Grandparents)

Foster Parents

Other

Interpreter Needed

YesNo

Other Language

Child Resides With

Contact 1

First Name*

Last Name*

Contact Phone*

Additional Phone

No Phone Available

Contact 2 (Optional)

First Name

Last Name

Contact Phone

Additional Phone

No Phone Available

Physical Address 1*

Physical Address 2

Zip Code*

City*

State*

County

If the Family/Caregiver has no phone, please provide an alternative contact

First Name

Last Name

Relationship

Phone Number

Your Information

Your First Name*

Your Last Name*

Title

Agency Type

Agency

Address 1*

Address 2

Zip Code*

City*

State*

Phone Number*

Extension

Additional Phone

No Phone Available

Fax Number