seamlessdocs@montgomerycountymd.gov
To get a hold of any of the programsl isted above, please reach out to the school itself and request to be connected to the program identified.
If student enrollment in at least one of the schools listed above is confirmed, you may continue with the referral form that follows by clicking the NEXT button.
Please note, the referral form will ask for detailed information about the student enrolled in one of the above schools, the parent/guardians, siblings, and needs of the family.
Do you have any concerns about completing the referral form? (Select the one the most applies to you, only one option may be selected)
Student Information
Student DOB
Household Address
Student's School Counselor Name
What type of insurance does this student have?
Student Insurance Information
Full Name
Date of Birth
Housing Services
Financial Services
Health Services
Family Services
Sibling 1 Name
Sibling 1 Date of Birth
Sibling #2 Name
Sibling #2 Date of Birth
Sibling #3 Name
Sibling #3 Date of Birth
Sibling #4 Name
Sibling #4 Date of Birth
Sibling #5 Name
Sibling #5 Date of Birth
CONSENT FOR PARTICIPATION AND DISCLOSURE OF INFORMATION
My signature below represents my consent to participate in the Cluster Project and gives permission to the Project Service Providers to use and share confidential information about the above-named children and me associated with the provision of benefits and services. It has been explained to me, in a language I understand, that I am consenting for my child and my family to participate in a project that will provide coordinated services to us that may involve Montgomery County Public Schools (MCPS), Montgomery County (MC) departments, Maryland State (MD) agencies, and local non-profit organizations.
This means my family will work with officials from government agencies that will coordinate resources to complement the educational services my child receives. I am aware that I can obtain more detailed information about the individual participants by reading the Memorandum of Understanding (MOU) for the Cluster Project that will be made available to me upon request. It has been explained that the intended purpose of this project is to jointly provide services in my child’s school, home and community that will help my child and my family and improve my child’s education. This consent to participate will be kept by the Project managers in a confidential file that is separate from my child’s school records.
By signing this consent form I agree to allow the participating agencies to accept a copy of this form as a valid consent to share information. I will not be told each time my information is shared unless I specifically ask to be told. This consent is valid for a period of twelve months. This consent may be revoked by me in writing at any time, and such revocation will prevent future disclosure to the extent that information has not already been released. Revocation will stop Service Providers from sharing information after they know that me consent has been withdrawn. It will not, however, prevent the use of information that was shared before I withdrew my consent. The Agencies participating in the Project that will be authorized to obtain access to your information on a need-toknow basis for the purpose of providing services to your family are:
Name and Signature of Person Completing Referral
