PPI Referral Form
Pathway to Potential Contact: Jonathan Rosewood at rosewood@capcan.org  or call 517-203-5011
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Sponsor organization name *
Date *
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Contact Person *
Phone number *
Email *
Client Name *
Birthdate
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YYYY
Address *
Email *
Phone *
Describe the barriers (at risk factors) that this client has to overcome to achieve their education/career goals and have they found ways to manage any of them? *
Please provide an example illustrating the client motivation to attain their short term education/career goal. *
Why do you believe this client is suitable, ready and wants the PPI coaching services? *
Non Discrimination Statement

It is the policy of the Capital Area College Access Network (CapCAN) that no discriminatory practices based on gender, race, religion, color, age, national origin, disability, height, weight, marital status, sexual orientation, political affiliations and beliefs, or any other status covered by federal, state, or local law be allowed in providing college and career coaching opportunities, programs, services, job placement assistance, employment or in policies governing student conduct and attendance. Individuals with disabilities will be referred to appropriate community-based services.  
 
Any person suspecting a discriminatory practice should contact the Executive Director at 517-203-5011.

Statement and Request to Share Information with Others

I have reviewed the above information and my signature below attests to the accuracy of all of the above information. I also I give permission to my sponsor organization to share the information above with CapCAN Pathway to Potential representatives.

Potential Client Signature *
Parent of Potential Client signature (if under 18 years old)
Sponsor Organization Representative Signature *
PPI Representative Signature *
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