Resources and Homeless Referral

Please complete this form if your family or a family that you are referring:

* Needs help applying for health insurance (Health First Colorado (formerly Medicaid) / CHP+)

* Needs access to community resources (food, clothing, counseling, etc.)

* Needs Homeless Assistance (please note that under the McKinney-Vento Act, students in any of the following situations may qualify for homeless assistance: students who are living "doubled up" with family or friends due to economic hardship; students who are living in inadequate housing that lacks proper utilities or electricity, windows or walls, or has an insect or rodent infestation; students who are living in homeless shelters; students who are living in parks or cars; students who are completely unsheltered; and students who are not living with their parent or guardian, involuntarily, due to economic hardship or family conflict)

Recipient Information

Student First Name *

Student Last Name *

Student Date of Birth *

Month

Day

Year

School

If the recipient listed above is a student please specify their school.

Student ID#

If the recipient listed above is a student please supply their student ID number.

County of Residence *

Phone

Parent / Guardian Name

If the recipient listed above is a minor please supply the name of their parent or guardian.

Household Language

Submitter Information

Submitter Name & Job Title *

Name of the person making this referral. If the referral is made by an Adams 12 employee, please include job title and school/building.

Submitter E-mail *

Submitter Phone

Best Time and Method to Reach Family

When Was the Family Notified That You Would be Making this Referral?

Reason for Contacting *

Health Insurance

Homeless Assistance

Community Resource

Comments: Please provide as much detail as possible. *

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Resources and Homeless Referral