Client Reference Form Information

 

An important part of the application process is reference forms.  No application is considered complete until at least three completed reference forms have been received.  These reference forms provide valuable information about a prospective client separate from the parental view point.

 

Please provide contact information for a minimum of three and a maximum of six individuals.  If you would like more than three references, please complete this form twice.  We will send each person a link for the reference form via their e-mail.  The form is to be completed and submitted on line.  If someone does not have access to e-mail, we will send out the form via regular mail. It would be helpful if you would contact those persons that you have asked to fill out reference forms and tell them they will be receiving an e-mail from PATCH with a link to the form.  

 

All information is confidential.  Fields with an * are required

 

Client Name: *
First Name
Middle
Last Name
Parent/Guardian Name: *
First Name
Middle
Last Name
Email Address*
Phone Number:*
Reference #1 Name: *
First Name
Middle
Last Name
Relationships to Applicant:*
Email Address:
Address
Address Line 1
Address Line 2
City
State
Postal Code
Phone Number*
Reference #2 Name: *
First Name
Middle
Last Name
Relationship to applicant:*
Email Address:
Adress:
Address Line 1
Address Line 2
City
State
Postal Code
Phone Number:*
Reference #3 Name *
First Name
Middle
Last Name
Relationship to Applicant:*
Email Address:
Physical Address:
Address Line 1
Address Line 2
City
State
Postal Code
Phone Number:*
By placing your initials below, you are authorizing Project PATCH to contact the above named individuals for references regarding the applicant as well as their family.
Initials:*
Are you submitting more than three references?
*

If you have any questions, please call 360-690-8495 or email us at patch@projectpatch.org