Make a Referral

Making a referral to DGCKids can be the first step toward a brighter future for a child who is blind or has a visual impairment.

DGCKids Referral Form

After you complete this Referral Form, a Referral Coordinator will contact the parent/guardian to talk through the next steps. We’re here to answer questions and provide support throughout the process.

"*" indicates required fields

Child's Name

First Last

Parent/Guardian's Name

First Last

Phone

Who is Completing this Form?*

If you ARE a parent, please answer the question below.

How did you learn about DGCKids?

If you are NOT a parent, please answer the questions below.

Please include the reason for the referral along with your name, organization, and contact information in case follow-up is needed. This helps our team make sure every child and family gets exactly the support they need to thrive.