JobReady Supports Referral Form

* Indicates a required field

School Name *

School Mailing Address (where gift card will be sent) *

Staff Name *

Staff Email *

Staff Phone *

Student Name *

Student Email *

Student Phone *

Please describe the intervention that will remove the barrier: *

Choose a payment option *

Target gift card

Gas gift card

Metro Transit card

Payment to vendor

Amount of payment needed *

Vendor Name

Vendor Address

Vendor Email

What barrier is the student facing? *

Free and reduce lunch eligible

Justice/ Foster Care or Child Welfare system involvement

Homeless or unsheltered

Individualized Education Plan

English Language Learner

Other

If other, describe the barrier that the student is facing:

By selecting, you are certifying that this student is enrolled at the school you are employed *

I certify.

By selecting, you are certifying that the identified student is eligible for the program and has the identified need *

I certify.

I understand that after Ramsey County mails gift card (if applicable), I am responsible to receive the gift card, provide it to the student and have the student sign to confirm their receipt of the gift card *

I agree.

I authorize Ramsey County Workforce Solutions to release information to and request information (third party payment/documentation or other) regarding education planning. I understand that my records are protected under the Minnesota Data Practices Act and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time by written notice. I understand that my revocation may not be made retroactive and will not apply where action had been taken in reliance upon it (e.g., probation, parole, etc.). This consent automatically expires one year after my file has been exited from the program. *

I authorize.

Today's date *

Month

Day

Year

JobReady Supports Referral

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JobReady Supports Referral

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