CVIPI Program Referrals Name of Person Being Referred to CPA (Required)(Required) First Middle initial Last Suffix Gender(Required)(Required)MaleFemaleNon-binaryAgenderMy gender is not listedPrefer not to answerParticipant Year of Birth(Required)Please enter a number from 1945 to 2009.Cell Phone to Contact IndividualCPA does not use phone numbers to solicit donations. If a mobile number is provided, CPA may occasionally reach out to participants using SMS messages to communicate important program updates.Email Address to Contact Individual Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Eligibility CriteriaIf Unknown, answer "No" Is the participant gang or street involved?((Required) Yes No Is the participant selling and/or using drugs?(Required) Yes No Is the participant currently criminal justice involved?((Required) Yes No Does the participant carry a weapon?((Required) Yes No Is the participant currently enrolled in school?(Required) Yes No Does the participant have previous criminal justice involvement?((Required) Yes No Do you have additional family contact info?(Required) Yes No Family contact InformationReferral Notes(Required)Referring Contact DetailsName of Referring Agency(Required)Referring Contact Name(Required) First Last Referring Contact Phone(Required)Referring Contact Email(Required) Consent to receive SMS communication I give consent.By submitting this form, you understand that COMPASS Youth Collaborative, Inc, a registered 501(c)3 nonprofit organization, may occasionally use SMS messages to communicate important program updates to you and its participants. These will never be marketing, spam, or to solicit your donation.CAPTCHA
