A Program of Catholic Charities

School/Agency Referral Form

This program is open to youth ages 7 to 17 who are attending school within Saratoga County. Child is matched with a caring adult for friendship and recreational outings.

Child Information

Name of Child *
Child's Date of Birth *
School/Grade *
Name of Parent/Guardian *
Street Address *
City, State, and Zip Code *
Home Phone *
Alternate Phone
Email Address *

Referral Information

Person making referral *
School/Agency *
Phone Number *
Email Address *
Reason for referral *
Obtained Parent/Guardian Consent to make the referral on (date) *
Youth's Strengths/Interests
Please include any other relevant information
Please confirm you are a human