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The Village Project Self Referral Form

The Village Project is here for you. By filling out our Self-Referral Form, you鈥檒l help us get a clearer picture of your needs so we can connect you with the right resources and services. Your privacy matters鈥攅verything you share will be kept confidential and used only to provide the support you request.

Name Name First Last
Phone Phone - ### - ### ####
Email
Student E#
Preferred Pronouns (Optional)
Have you been in any of the following situations before the age of 18? (Select all that apply)

Have you been in any of the following situations before the age of 18? (Select all that apply) Foster Care Kinship care (living with a relative who is not your parent Group home or residential care Legal guardianship with a non-parent Independent living without a parent or guardian None of the above
At what age did you leave foster care or alternative care arrangement (if applicable)?

At what age did you leave foster care or alternative care arrangement (if applicable)? Still in care Under age 18 Age 18 or older (aged out) N/A Other Other
What type of support are you hoping to receive while in college? (Select all that apply)

What type of support are you hoping to receive while in college? (Select all that apply) Help with housing (on or off campus) Academic support (tutoring, study skills) Financial assistance or help navigating scholarships/grants Emotional or mental health support Connection with other students from similar backgrounds Life skills or transition support (budgeting, cooking, time management, etc.) Support with employment or career planning Other (please describe): Other Other
Any questions, comments, or special request.