JOHN’S CLOSET REFERRAL FORM   (please print and fax or mail)

REFERRED BY: TODAY’S DATE:_____________________

NAME OF PARENT OR GUARDIAN:_____________________________________

ADDRESS (MUST INCLUDE CITY): ______________________________________

________________________________________________________________________

TELEPHONE NO.: ______________________________________________________
(NOTE: If Non-English Speaking, Please Provide Name and Telephone Number of an English Speaker That We Can Contact to Schedule An Appointment)

BEST TIME TO CONTACT: _____________________________________________

HOUSEHOLD MONTHLY INCOME: _____________________________________

SOURCE OF INCOME (If Job List Type of Job): ____________________________

NAME OF EACH CHILD  and AGE:

____________________________   _____            ____________________________   _____  

____________________________   _____            ____________________________   _____  

____________________________   _____            ____________________________   _____  

____________________________   _____            ____________________________   _____  

____________________________   _____            ____________________________   _____  

____________________________   _____            ____________________________   _____  

WHEN COMPLETED – FAX THIS FORM TO  (650) 875-7743

QUESTIONS? CALL DIANE OR GINA@ (650) 871-7440