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Referral Form

Thank you for making a difference!

Referring is easy!

All CCC clients must be referred by a social service agency, school, church or organization.

*Please open the form in Adobe Reader to use the Email and Print buttons at the bottom of the form.*

The completed form may be submitted to

Once the referral is completed by the referring agency, the client will need to bring their driver's license and social security cards for each family member who lives in the same household listed on the referral. Please be sure to tell this to the client. Once the CCC receives the form, the person(s) will be registered and eligible to shop twice a month for a year.