ELRC7 Resource and Referral Request
By answering the questions below, we will be able to send you information about other services you may need.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Number of Children in your Household
*
(If no children in your household, please fill in 0)
Ages of the Children in your Household
*
(If no children in your household, please fill in 0)
Are you 55 years of age or older and raising a relative 18 years or younger?
*
Yes
No
Do you need help finding child care or early education programs for your children?
*
Yes
No
Do you need help finding a quality child care program to meet the needs of your child and family? The ELRC can help you locate a quality child care program.
Yes
No
Would you like information about Pre-K Counts? If you have a child between the ages of 3 and 4, you may be eligible for Pre-K Counts. You do not have to be employed to receive Pre-K Counts.
Yes
No
Would you like information about Early Head Start or Head Start? If you are pregnant, have a child from birth up to 3 years old, you may be eligible for Early Head Start. If you have a child from 3 to 5 years old, you may be eligible for Head Start. You do not have to be employed to receive Head Start or Early Head Start.
Yes
No
Do you or members of your family need assistance finding health insurance or healthcare options?
*
Yes
No
Does your child(ren) need health insurance? Pennsylvania's Children's Health Insurance Program (CHIP) provides health insurance to children and teens who are not eligible for or enrolled in Medical Assistance.
Yes
No
Do you need dental care?
Yes
No
Do you need vision care?
Yes
No
Do you need health insurance?
Yes
No
Do you or members of your family need assistance securing food?
*
Yes
No
Would you like information on Pennsylvania's supplemental food program for Women, Infants, and Children (WIC)? If you are pregnant, breastfeeding, not breastfeeding, or have an infant or children under age five, including foster children, you may meet the requirements to receive nutritional support from the WIC program.
Yes
No
Do you need help paying for food? (SNAP)
Yes
No
Would you like information about free and reduced school meals for your school age child(ren)?
Yes
No
Are you concerned about your child's development?
*
Yes
No
Would you like information about Pennsylvania's Home Visiting Programs? Home Visiting Programs provide resources and skills to help raise children who are physically, socially, and emotionally healthy and ready to learn. If you are: pregnant, an expectant father, a parent, a caregiver of children, or a member of a family that may be considered at-risk, you may be eligible.
Yes
No
Do you need assistance with housing and/or paying utilities?
*
Yes
No
Do you need help paying for your heating, electric, or gas? The Low Income Home Energy Assistance Program (LIHEAP) help slow income families pay their heating bills. The payments would go directly to the utility company if you qualify.
Yes
No
Do you need information about housing or rental assistance?
Yes
No
Do you or members of your family need educational or employment assistance?
*
Yes
No
Would you like to take classes to learn English as a second language (ESL)?
Yes
No
Would you like to enroll in a program to get your high school equivalency diploma (GED)?
Yes
No
Would you like to enroll in a job training program?
Yes
No
Would you like information about the Earned Income Tax Credit (EITC)? You may be eligible for an EITC if you work and earn low to modest incomes. If you are eligible, you may pay less federal taxes, no taxes, or get a refund.
Yes
No
Submit
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