Opportunity Passport Referral Form
Referrer First Name
Referrer Last Name
Referrer's Phone Number
Agency Address (Street, City, State, Zip)
Referrer's Email Address
Student Email Address
Student Phone Number
Student Social Security Number
Student Date of Birth
Which Financial Literacy Class are you referring this student for?
Terre Haute, IN (3 day class
Orientation: February 21, 2020; 4pm-7pm
Class Day 1: February 22, 2020; 9am-3pm
Class Day 2: February 23, 2020; 9am-3pm
Muncie, IN (3 day class
Orientation: March 6, 2020; 4pm-7pm
Class Day 1: March 7, 2020; 9am-3pm
Class Day 2: March 8, 2020; 9am- 3pm
Evansville, IN (3 day class)
Class Day 1: TBD
Class Day 2: TBD
Please state how participation in this program will benefit the student.
Does student have the maturity to benefit from the training?
Does the student have a valid form of identification (drivers license, state ID, passport, etc.)?
Is the student allowed to have access to the internet (e-readers are used for class)?