Emergency Aid Referral Form

Referrer's Information

Student Knowledge*

Have you had a conversation with this student concerning his/her needs?

Yes

No

Referral Agency/Entity

Name & Title of Agency Contact

Phone

Email

Name of GC Referrer

GC Referrer's Phone

GC Referrer's Email

Student's Information

Student's Last Name*

Student's First Name*

Student's GC ID

(if known)

Student's Address

Please include street, city, state and zipcode

Household*

How many people are in the student's household?

Student's Needs

Public Beneftis*

The student needs information/assistance to access public benefits.

Yes

No

Unsure

Assistive Device(s)*

Student requires assistive device(s).

Yes

No

Unsure

Food*

Student needs additional food.

Yes

No

Unsure

Housing*

Student needs assistance with obtaining housing.

Yes

No

Unsure

Utilities*

Student needs assistance with utilities/telephone.

Yes

No

Unsure

Health/Dental*

Student needs assistance with health or dental issues.

Yes

No

Unsure

Transportation*

Student needs assistance with transportation, gasoline or vehicle repair.

Yes

No

Unsure

Medication*

Student needs assistance with medication.

Yes

No

Unsure

Material Items*

The student needs assistance with clothing, furniture or household items.

Yes

No

Unsure

Other

If the student has needs not addressed above, please explain below.

The submission of this application allows the Grayson College Emergency Aid Committee permission to contact local community services and agencies on the student's behalf.

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