REFERRAL SOURCE AND PRINCIPAL / DESIGNATE AUTHORIZATION

School board

Your referral code

Your Name

Your Role

Your Email

Your School Name

Complete School Address

School's phone number

Does the principal or designate support referral for services?

YES NO

Consent

This request for referral is being submitted with the knowledge and consent of Student / Parent / Guardian

YES NO

Student / Parent / Guardian grant consent to have ErinoakKids enter referral information into its database.

YES NO

Do you acknowledge that ErinoakKids will exchange and share information with the school and school board, and the school that the child is attending within ErinoakKids catchment area, AND THAT the school board and the school will share information back with ErinoakKids.

YES NO

Save this info for 30 days on this computer (optional)

You did not enter a postal code from our region and are not eligible to complete an online referral. If you live in the region and believe this is an error, contact 1-877-374-6625 for support.