Student Referral - George Washington Carver Elementary

Your Information
Please make sure you complete this section with “YOUR” information so we can keep you updated with the progress of this referral and contact you if need be. Thank you.
First Name*
Last Name*
Email Address*
Phone Number*
How would you like to receive notifications?
Relationship to Student*

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Student Information
Please make sure to fill out this section fully so we can ensure that care package is delivered to the correct student. Thank you
Agency/School Name*

Agency/School Name
Agency/School Zip Code*
ZIP Code

Homeroom Teacher

If applicable
Student Initials*

Student Grade Level*
Gender*
Student Ethnicity*
Student Status*
Homeless
Not Homeless
If Homeless, Please Select one of the Following Drop Downs*
Reason for Student Referral*
Create Care Package
Please tell us about the student and the background for the request.
This will help us to serve the students needs and understand the student's situation.
Student Clothing Style Preferences*
Is the student a girly-girl? A tomboy? Love the cowboy look? Let us know!

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Clothing Items Needed
Please work with the family/caregiver to get appropriate sizes and style preferences.
Uniform Color(s)
Uniforms Sizes
Size Type*
Toddler Pants Sizes (unisex)
Toddler Top Size (unisex)
Youth Pants Sizes (unisex)
Youth Top Sizes (unisex)
Junior Pants Sizes (Teen Girls only)
Junior Top Sizes (Teen Girls only)
Women Pants Sizes
Women Top Sizes
Bras (Females Only)

Mens Pants Sizes Waist (includes Young Men)
Mens Pants Sizes Length (includes Young Men)
Mens Top Sizes (includes Young Men)
Underwear (Male or Female)
Size determined based on previous selections.
Socks (Male or Female)
Size determined based on previous selections.
Shoes (Male or Female)
Uniform Bottoms
Select All
Bottom: Black
Bottom: Khaki
Bottom: Navy Blue
Select multiple
Uniform Tops
Select All
Top: Baby Blue
Top: Forest Green
Top: Goldenrod Yellow
Top: Maroon
Top: Navy Blue
Top: Red
Top: Royal Blue
Top: White
Top: Black
Top: Purple
Select 1-3 color choices
Hygiene Items
Hygiene Kits
Body Kit - Soap, Shampoo/Conditioner (Lotion, when available)
Dental Kit - Toothbrush, Toothpaste (Floss, when available)
None
Miscellaneous Hygiene Items
Body Lotion
Deodorant
Soap
Shampoo/Conditioner
Toothbrush/Toothpaste
Floss
None
Individual items if needed
Feminine Hygiene
Pads Only
Tampons Only
Both Pads/Tampons
None
School Supplies
Select All
Backpack
Pens / Pencils / Paper
Composition Notebooks
Folders / Binders
Gluestick / Art Materials
Spiral Notebooks

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Verification
Verification (The GCP is designed to help students from low income families who qualify for free or reduced lunch. We ask that you check this box as verification that you are requesting items for a student in need whom, to the best of your knowledge, is unable to obtain necessary items needed for success in school)*
By checking this box, you verify that you are requesting items for a student in need
Family Outreach (In an effort to de-stigmatize situational poverty, The GCP asks that you contact the caregiver of the student in need to make them aware of our organization and the referral you have completed for their child)*
By checking this box, you affirm that you will attempt to contact the student's family
Email
This field is for validation purposes and should be left unchanged.

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Student Referral – George Washington Carver Elementary

Student Referral - George Washington Carver Elementary

Step 1 of 4

Your Information

Student Information

Create Care Package

Clothing Items Needed

Uniforms Sizes

Hygiene Items

Verification