Skip to main content

Locations

Languages

Donate

Girls RAP Referral Form

Girls Resolution and Prevention Diversion Program Referral

Thank you for filling out this referral form for YWCA Minneapolis Girls RAP program. Questions? Please contact girlsrap@ywcampls.org or 612-215-4123.

Fields marked with a * are required.

Referral Agency:*
Referring Person:*
Referring Person Email*
Referring Person Phone:*
Participant's Name:*
First Last
Age:*
Date of Birth:*
MM slash DD slash YYYY
Race:*
- African
- Black
- White
- Asian/Pacific Islander
- Hispanic
- Multiracial
Parent/Guardian Name:*
Phone:*
Address:*
Street Address Address Line 2 City State ZIP Code
Date of Referral:*
MM slash DD slash YYYY
Reason for referral/concerns with problems with youth:*
File
Max. file size: 100 MB.
Phone
This field is for validation purposes and should be left unchanged.