Case Managers - Women Giving Back

Santa's Workshop Client Referral

Case Manager's Full Name*

Full Name

Case Manager Email*

Case Manager Phone*

Please list a phone number that you can be reached at the day of the event.

Shelter/Program Name*

I understand*

that completing this referral form does NOT guarantee my client will receive holiday assistance.
that WGB crosschecks their holiday list with other organizations to avoid duplication.
that it is my responsibility to communicate event information, approval and denials with my client.

Verification*

I confirm that my client has an active service plan with my organization.
I have verified my client's need for holiday assistance.
I confirm that my client will not be receiving holiday assistance from my organization.
I have confirmed with my client that they are not registered with any other holiday assistance program.

Client's Name (as it appears on their photo ID they will present)*

First Last

Click to select a date & time*

Client's Date of Birth (mm/dd/yyyy)*

Client's Full Address*

Street Address City ZIP / Postal Code

Client's # of Children (17 and under)*

Please list all children (17 and under). Click the + sign to add additional kids*

Child's Full Name	Age	Boy/Girl

Comments

This field is for validation purposes and should be left unchanged.