Download Referral Form (PDF) Referral FormChild or Youth’s InformationFirst NameLast NameDate of BirthChild's Gender- Select -MaleFemaleAgenderBigenderTransgender MaleTransgender FemaleGenderqueerIs child of First Nations, Metis, Inuit heritage? Yes(for reporting purposes only)FREE Program(s):Select Free Programs Infant Development Program (0 to 3) Physiotherapy (0 to school entry) Occupational Therapy (0 to school entry) Supported Child Development (0 to school entry) Fetal Alcohol Spectrum Disorder (FASD) Keyworker (0 to 18) Family Support Worker Program (For parents with children 0 to 18) A Pathway to Hope (0 to school entry) 2SLGBTQI Program (1 to 1 support (8 -18yrs), Family Support, Youth Drop-in Group (13 – 18yrs))Child Care CentreFEE FOR SERVICE Program(s): There is a fee for these services. Families can pay through autism funding, distributed learning funding, or private funds. Select Fee For Service Programs The Nest Positive Behaviour Support Services (0 to 5 at start of service) FLY @ffinity (8 to 13, participate without 1-1 support) Friends & Leisure Youth Program (8 to 18, participate without 1-1 support)Parent/GuardianFirst NameLast NameContact #Relationship to Child- Select -ParentFamily MemberFoster ParentSWParent/GuardianFirst NameLast NameContact #Relationship to Child- Select -ParentFamily MemberFoster ParentSWSelf Contact Information (for 2SLGBTQI Program registrants)First NameLast NameContact #Additional InformationPhysical AddressAddress Line 1CityPostal CodeEmailWould you like to receive Shuswap Children’s Association’s workshop/event email notifications? Yes NoIs Mailing Address the same as Physical Address? YesMailing AddressAddress Line 1CityPostal CodeFamily DoctorPediatricianDiagnosis (if known)Reason for ReferralAttachment per referralChoose File Consent for ProgramsIf you don't see a consent checkbox, please ensure you've selected either a FREE or FEE FOR SERVICE program.Parent/Legal Guardian consent is required to receive service. I consent to receive serviceGiving personal consent is required to receive service. I consent myself for LGBTQ+ serviceName of Parent/Legal Guardian completing this form and giving consentReferred byFull Name PleaseContact #Agency/Title/ParentDateSubmit Form