Make a Referral

Parent/Guardian Name *

Girl's Full Name *

School *

Grant or Deny Permission

I, the undersigned, do herby grant grant or deny permission to the Delores Barr Weaver Policy Center for the following:

Section 1 *

To use the image of my child, and Their grade and age, as marked by my selection below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, voice recording, and/or video taken of my child and/or family for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Delores Barr Weaver Policy Center’s website: www.seethegirl.org.

Section 2 *

To release information about my child’s individual needs to a referral agency such as (Full ServiceSchools, Girl Scouts) if eligible to receive additional services and supports to increase her success. This may include your child’s name, date of birth, needs she is demonstrating, as well as your contact information.

Section 3 *

To provide reporting information to the Florida Department of Juvenile Justice Prevention Web system (JJIS) on the demographics and needs of girls served through the It’s Elementary program as per grant requirements. All information will be confidential.

Section 4 *

To access the school records of my child and allow use of the information for grant reporting purposes in order to provide information including number of absences and suspensions of all girls served to funders such as (the Department of Juvenile Justice and The Remmer Family Foundation). All information will be kept confidential.

Date *

I acknowledge that I understand and agree with the Youth Rights Policy and Rights and Grievance Procedure provided to me by the Delores Barr Weaver Policy Center.

Parent/Guardian Full Name *

Phone Number *

I certify that I am the legal guardian of the above named girl. *

Signature *

Referral Form for GMIC or Open Doors

Name of the person/agency making the referral *

Phone *

Email *

Referred Person's Name *

Date of birth *//

Date / Time *

Referred Person's Contact Information *

Parent/Guardian Name and Contact Information *

Is the person involved with Juvenile Justice System? *

Any other community organization(s) involved with the person? *

Please briefly describe the reason for seeking services with the Delores Barr Weaver Policy Center? Which services are you interested? *

Currently enrolled in school? If yes, where and last grade completed? *

How did you hear about the Delores Barr Weaver Policy Center? *

Name

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