Referral Form

Is this referral for your own family or someone else?(Required)

My Family

Someone Else

Referring Person's Name(Required)

First Last

Referring Organization

Referring Person's Phone Number

Referring Person's Email(Required)

Enter Email Confirm Email

If the referral is on behalf of someone else, have they expressed interest in working with Back2Back?

Yes

Name of Household Primary Caregiver(Required)

First Last

Phone of Primary Caregiver(Required)

Name of child(ren), age(s), and school(s) in the household?(Required)

Child Name

Age

School

What neighborhood does the family live in?(Required)

What is the family's primary language?(Required)

Briefly describe the challenges the family needs assistance with:(Required)

Are any youth in the home involved with the juvenile court system?(Required)

Yes

Unknown

Are there any other organizations the family is connected to?(Required)

Yes

Unknown

What organizations and services are being utilized by the family?(Required)

Name of Organization

Services Utilized by Family

Next Steps

Thank you for making a referral. Back2Back Cincinnati engages with the whole family. Thus it is important that families we come alongside are invested in the process and have a voice in their stories. There are times Back2Back Cincinnati is not the right fit for families, so making a referral does not guarantee Back2Back Cincinnati will be able to assist the family. However, Back2Back Cincinnati staff reach out to everyone who submits a referral to talk through next steps in the referral process.

Release of Information

Name of Participant(Required)

First Last

Release of Information (ROI) Consent

I understand my student’s story and/or my story is ours to share. I understand Back2Back Cincinnati will hold our information confidential unless necessary by law. I realize Back2Back Cincinnati can better serve my student and/or our family when they communicate to other individuals working with my student and/or our family. I give permission for Back2Back Cincinnati to give and receive information in regards to my student(s) and/or myself from Hamilton County Juvenile Detention Center (20/20), Hamilton County Juvenile Probation, Hamilton County Public Defender’s Office, Hamilton County Diversion Court Programs, Hamilton Prosecutor’s Office, and Hamilton County Juvenile Court.

Name of Consenting Guardian or Student (if over 18)(Required)

Submitting your name below as a digital signature, you are acknowledging any release of information and understand that the permission can be revoked at any time by contacting Back2Back Cincinnati in written format either in email or letter.

First Last

Date(Required)

Provide the date of consent and submission of this form.

Student Name(Required)

First Last

Additional Student Name

First Last

Parent/Guardian Name(Required)

First Last

Field Trip Consent

Please provide consent or deny consent for the following planned field trip. A Yes or No response is required for every field trip. "Yes" indicates consent while "no" will result in a denial of consent and your student will not be able to participate in the activity.

Newport Levee | Monday 6/10/24 | 2:30-4:30(Required)

One Levee Wy, Newport, KY 41017 | Pick Up at 2:30 pm, Drop Off at 4:45 pm

Yes

Mt. Echo | Monday 6/17/24 | 2:30-4:30(Required)

251 Mt Echo Park Dr, Cincinnati, OH 45205 | Pick Up at 2:30 pm, Drop Off at 4:45 pm

Yes

Dunham Pool | Monday 6/24/24 | 10-2(Required)

4356 Dunham Ln, Cincinnati, OH 45238 | Pick UP: 9:45 Drop OFF: 2:15 | Swimsuit Required

Yes

Kings Island | Monday 7/1/24 | 10-3(Required)

6300 Kings Island Dr, Mason, OH 45040 | Pick UP: 9:45 Drop OFF: 3:15

Yes

French Park | Monday 7/8/24 | 2:30-4:30(Required)

3012 Section Rd, Cincinnati, OH 45237 | Pick UP: 2:15 Drop OFF: 4:45

Yes

FC Cincinnati Game | Saturday 7/13/24 | 7:30-9:30(Required)

1501 Central Pkwy, Cincinnati, OH 45214 | Pick UP: 7 Drop OFF: 10

Yes

Washington Park | Monday 7/15/24 | 2:30-4:30(Required)

1230 Elm St, Cincinnati, OH 45202 | Pick UP: 2:15 Drop OFF: 4:45

Yes

Smale Riverfront Park | Monday 7/22/24 | 2:30-4:30(Required)

166 W Mehring Way, Cincinnati, OH 45202 | Pick UP: 2:15 Drop OFF: 4:45

Yes

Mt. Echo | Monday 7/29/24 | 2:30-4:30(Required)

251 Mt Echo Park Dr, Cincinnati, OH 45205 | Pick Up at 2:30 pm, Drop Off at 4:45 pm

Yes

Spruce Nails | Monday 8/5/24 | 2:30-4:30(Required)

1818 Race St Suite 101, Cincinnati, OH 45202 | Pick UP: 2:15 Drop OFF: 4:45 | Your student will be getting their nails painted

Yes

Digital Signature of Consenting Guardian or Student (if over 18)(Required)

By filling out your name as the parent, guardian, or consenting student (if over 18) below, you are signing in agreement with Back2Back's ability to take your child on extracurricular activities. This digital signature serves as an additional form of consent along with the choices above.

First Last

Date of Submission(Required)

Comments

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

Next Steps

Sponsor A Child or Family

Release of Information

Release of Information (ROI) Consent

Take A Mission Trip

Field Trip Consent

Job Inquiry Form

Write A letter

Back2Back Intern Application