FRYSC STUDENT REFERRAL FORM
ALL INFORMATION IS COMPLETELY CONFIDENTIAL !
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Email *
Student's Name *
Student's Age *
Student's Birthday *
Student's grade *
Do they qualify for Free/Reduced lunch? *
Student's teacher *
Student's parent/guardian *
Parent/guardian phone number *
Full address (with street, city, state, zip code and apt number if applicable) *
Who were you referred by? *
Please check ALL that apply or explain in the comments.

Educational Support 
 *
Required
Please check ALL that apply or explain in the comments.

Health Services/Referrals
 *
Required
Please check ALL that apply or explain in the comments.

Basic Needs/Social Support
 *
Required
Please check ALL that apply or explain in the comments.

Family Crisis/Intervention
 *
Required
Please check ALL that apply or explain in the comments.

Holiday Assistance
 *
Required
Please check ALL that apply or explain in the comments.

Child Care/Referral
 *
Required
Please check ALL that apply or explain in the comments.

Parenting
 *
Required
Other (Please use this space to elaborate on any responses above or to add any other types of support or assistance that you need): *
Comments: *

KRS 620.030(1)- Anyone with a reasonable suspicion that a child is dependent, abused or neglected is required to make a report to the Cabinet for Health and Family Services (CHFS) https://prd.webapps.chfs.ky.gov/reportabuse/home.aspx

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