Artemis Place Referral Form

    Your Name (required)

    Your Email (required)

    Applicant's Legal Name (required)

    Applicant's Preferred Name (required)

    Applicant's Phone Number (required)

    Applicant's Email (required)

    Birth date (required)

    Gender Identity (required)


    Is applicant pregnant or parenting? (required)


    If yes, due date or age of child?

    School last attended (required)

    Date last school attended (required)

    Last grade completed (required)

    What challenges have made school a struggle? (required)

    Why does Artemis Place seem like a good fit? (required)

    Does the applicant know any current students? (required)


    If yes, who?

    What organization or who recommended Artemis Place? (required)

    Parent/Guardian Name (required)

    Relationship (required)

    Parent/Guardian Phone Number (required)

    Parent/Guardian Email (required)