Child's Name *

First Name

Last Name

Gender *

Male

Female

Ethnicity *

Hispanic

Non-Hispanic

Not Available

Refused

Race *

White

Black/African-American

American Indian/Alaska Native

Asian

Hawaiian/Pacific Islander

Date of Birth *

MM

DD

YYYY

Parent/Primary Caregiver Name *

First Name

Last Name

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Other Phone

(###)

###

####

Referral Source (Person Making the referral) Name

First Name

Last Name

Referrer Phone

(###)

###

####

Select to Agree as Primary Caregiver

I affirm that the facts set forth in this application are, to the best of my knowledge, true and complete. I give permission to Children's Home Network and its representatives to contact the parent/caregiver of the child entered in this RAISE application in connection with my desire to seek services with the RAISE program. Disclaimer: Please forward a copy of the child’s most recent report card. Your application may be delayed if the application is not legible and/or the aforementioned documents are not submitted.

Select to Agree as a Referrer

I acknowledge that I am not the parent/caregiver of this child, and that I have spoken with the parent/caregiver and I have received their consent for submission. I affirm that the facts set forth in this application are, to the best of my knowledge, true and complete. Disclaimer: Please forward a completed copy of the Hillsborough County Schools Authorization for Release of Records form along with a copy of the child’s most recent report card. This application may be delayed if the application is not legible and/or the aforementioned documents are not submitted.

Date

MM

DD

YYYY