ELRC7 Resource and Referral Request

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / 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?

Do you need help finding child care or early education programs for your children?

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.

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.

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.

Do you or members of your family need assistance finding health insurance or healthcare options?

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.

Do you need dental care?

Do you need vision care?

Do you need health insurance?

Do you or members of your family need assistance securing food?

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.

Do you need help paying for food? (SNAP)

Would you like information about free and reduced school meals for your school age child(ren)?

Are you concerned about your child's development?

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.

Do you need assistance with housing and/or paying utilities?

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.

Do you need information about housing or rental assistance?

Do you or members of your family need educational or employment assistance?

Would you like to take classes to learn English as a second language (ESL)?

Would you like to enroll in a program to get your high school equivalency diploma (GED)?

Would you like to enroll in a job training program?

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.