Clarksville Cares - Referral Form
The form below is one way you can share information of a student you know is in need of assistance.  This could include living arrangements, food, clothing, medical needs, and/or school supplies.  Fill in as much information as you can.  A guidance counselor or administrator will reach out to provide resources and support the student in need.

Provide as much information as you can on the form below.  If you provide your contact information, we may get in touch with you to gain more insight prior to contacting the student in need.  We will do everything we can to preserve your anonymity, but cannot promise complete confidentiality.
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Student #1 name (LAST, FIRST): *
STUDENT INFORMATION #1
Student #1 email address:
Student #1 phone number:
Student #1 year/grade in school: *
Required
STUDENT INFORMATION #2
Student #2 name (LAST, FIRST):
Student #2 phone number:
Student #2 email address:
Student #2 year/grade in school:
STUDENT INFORMATION #3
Student #3 name (LAST, FIRST):
Student #3 phone number:
Student #3 email address:
Student #3 year/grade in school:
STUDENT INFORMATION #4
Student #4 name (LAST, FIRST):
Student #4 phone number:
Student #4 email address:
Student #4 year/grade in school:
CONTACT INFORMATION
Your name:
Your relationship to student:
Your phone number:
Your email address:
Would like us to contact you?
NATURE OF CONCERN / NEED
Please check all the following CLOTHING items needed:
Please list the SIZE(S) needed for each clothing item.
Please list any additional CLOTHING items needed that are not listed above.
Is there a need for SCHOOL SUPPLIES?
If there is a need for SCHOOL SUPPLIES, please specify below:
Is there a need for HOUSING?
Is there a need for MEDICAL CARE?
If there is a need for MEDICAL CARE, please specify below:
Is there a need for FOOD assistance?
If you are in need of FOOD assistance, please specify below:
Is there a need for assistance with PAYING BILLS?
If you are in need with assistance for PAYING BILLS, please specify below:
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