Pomona Valley Coronavirus Emergency Fund, Referral Form to Uncommon Good
The Pomona Valley Coronavirus Emergency Fund, by Uncommon Good, is meant to address some short-term emergency expenses of families in the Pomona Valley community (i.e. Montclair, Ontario, Pomona, Rancho Cucamonga, San Dimas, Upland, Walnut, Chino, Chino Hills, Claremont, Diamond Bar, Glendora, La Verne).

Please fill out this REFERRAL FORM to the Pomona Valley Coronavirus Emergency Fund, by Uncommon Good, on behalf of your client. The information collected will helps us determine eligibility and keep a fast, streamlined processing of emergency fund grants. Clients will be contacted by Uncommon Good based on the information you provide.

*Submit only ONE referral per household. Applications will be reviewed on a first-come, first-serve basis.

For questions or inquiries, contact Carlos D Carrillo, Educational Programs Director via e-mail at ccarrillo@uncommongood.org or via phone at (909) 625-2248.
Name of Agency Person Filling Referral: *
Email of Agency Person Filling Referral: *
Referral Agency: *
Full Name of Client: *
Client Street Address: *
Client City: *
Client ZIP Code: *
Client County: *
Client Phone Number: *
Client Email Address: *
Client Household Size: *
Client Household Members: *
Name and age only. i.e. (Juan Lopez - 52, Tina Lopez - 50, Miguel Lopez - 15)
How long has the client/family been affiliated with your agency? *
What type of services is the client receiving through the agency? *
Required
Client Area of Need: *
Check all that apply
Required
Estimated Amount of Client Need: *
Referral Notes /Client's story *
Tell us how your client has been affected by the Coronavirus pandemic. Share what you think will be important for us to know about their situation. Be VERY SPECIFIC and include what language they prefer.
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