Referral - QC Step

Student Information

Name

Student SSN

Student DOB

Anticipated Grad Date

Disability(ies)

Cell Phone Number

Email Address

Insurance or Medicaid

Other Public Assistance

Student SSN

Parent/Guardian Information

Primary

Parent
Guardian

Name(s)

Contact Phone

Physical Address

Mailing Address

Employer(s)

Monthly Income

Parent/Guardian Information

Receive Communication?

Yes
No

Relationship

Name(s)

Contact Phone

Physical Address

Mailing Address

Employer(s)

QC Step

Kimberly is a recent graduate of United Township High School. While in STEP classes, she participated in training sites, which ultimately resulted in paid work opportunities. Kimberly said, “Because I trained while in high school, they were able to see my skills, and I was able to get a part-time job my senior year. I was able to talk to people more and it helped me to be less shy.”