PDX Bridge referral form

PDX Bridge

"*" indicates required fields

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Referrer information

Agency contact (your name)*

Referring agency (e.g. DHS, DJJ, or ILP)

Your phone number

Your email*

Student information

Student's birthdate*

Student's name*

Student's email

Student's contact number (can be through agency if needed)*

Current educational placement: school/program

Student meets minimum 9th grade reading level through*

What other way does the student meet the minimum 9th grade reading level?*

We aim to work with students who could most benefit from a supported transition to college. Check all that apply below. Student has experienced

Foster care

Adjudication (involvement in the justice system)

Homelessness or housing insecurity

Other

When is the student projected to graduate with a GED® or diploma?*

Please describe why you think this student will benefit from this program, and describe what traits they possess that will help them make the best of this opportunity?

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