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 (optional)

First Last

Parent/Guardian's Name

First Last

Phone

Who is Completing this Form?*

For parents, please answer the questions below.

Include how you heard about DGCKids, and your reason for referring. A member of DGCKids will reach out with next steps!

For others, please answer the questions below:

Include the reason for the referral along with your name, organization, and contact information. A member of DGCKids will reach out in case follow-up is needed. This helps our team connect the child and family with the most appropriate services and support.