HelpOurKids Pen Pal Child Referral Form
This form is for social workers to submit a referral for a child to be added to the HelpOurKids Pen Pal program.
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Child's name *
Child's date of birth
MM
/
DD
/
YYYY
Child's age
Child's sex
Clear selection
Child's pronouns *
Child's ethnicity
Child's primary language
Child's grade in school (for example: 9th grade)
Child's type of placement
Name of contact person at child's placement
Phone number of contact person at child's placement
Email address of contact person at child's placement
Child's interest (check all that apply)
Provide more detail about above interests
Use this space to provide any more information about the child's interests or additional details about the items you selected above.
Child's favorite color
Any additional information
Let us know below if you would like to share any additional information.
Name of social worker
Social worker's phone number
Social worker's cell phone number
Social worker's email address
Social worker's DCF area office
Clear selection
Name of social worker's supervisor
Phone number of social worker's supervisor
Email address of social worker's supervisor
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