{"id":9341,"date":"2023-01-25T15:44:03","date_gmt":"2023-01-25T23:44:03","guid":{"rendered":"https:\/\/www.palomar.edu\/foundation\/?page_id=9341"},"modified":"2026-06-08T10:59:11","modified_gmt":"2026-06-08T17:59:11","slug":"referral-form","status":"publish","type":"page","link":"https:\/\/www.palomar.edu\/foundation\/referral-form\/","title":{"rendered":"Emergency Grant Referral form"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_12' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Emergency Grants &#8211; Faculty, Administrator or Staff Referral<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_12'  action='\/foundation\/wp-json\/wp\/v2\/pages\/9341' data-formid='12' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_12' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_12_20\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >\n\n\n<!-- HTML Codes by Quackit.com -->\n<title>\n<\/title>\n\n\n\n\n\n<h1><\/h1>\n<p>If you know a student experiencing a an emergency situation that is a barrier to education, please have a faculty or an administrator complete the online referral form to be considered for emergency funding or a laptop. Emergency grants range from $50 \u2013 $250. Requests are reviewed on the next available Tuesday and are limited to one student per semester.<\/p>\n\n\n<\/div><fieldset id=\"field_12_8\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-two-thirds gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name of Faculty, Administrator or Staff<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_12_8'>\n                            \n                            <span id='input_12_8_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_12_8_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_8.3' id='input_12_8_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_12_8_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_12_8_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_8.6' id='input_12_8_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_12_9\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_9'><span class='gform-field-label__text'>Faculty, Administrator or Staff Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_9' id='input_12_9' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_12_10\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_10'><span class='gform-field-label__text'>Faculty, Administrator or Staff Phone*<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_12_10' type='tel' value='' class='large'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><fieldset id=\"field_12_14\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-two-thirds gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name Of Student<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_12_14'>\n                            \n                            <span id='input_12_14_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_12_14_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_14.3' id='input_12_14_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_12_14_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_12_14_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_14.6' id='input_12_14_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_12_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_15'><span class='gform-field-label__text'>Student ID #<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_12_15' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_18\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_18'><span class='gform-field-label__text'>Student&#039;s Email<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_18' id='input_12_18' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_12_19\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_19'><span class='gform-field-label__text'>Student&#039;s Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_19' id='input_12_19' type='tel' value='' class='large'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_12_21\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_21'><span class='gform-field-label__text'>Student Need<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_21'>For assistance with textbooks, please visit the Financial Aid website. <\/div><div class='ginput_container ginput_container_select'><select name='input_21' id='input_12_21' class='large gfield_select'  aria-describedby=\"gfield_description_12_21\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Emergency Grant' >Emergency Grant<\/option><option value='Laptop Assistance Funding' >Laptop Assistance Funding<\/option><\/select><\/div><\/div><div id=\"field_12_16\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_16'><span class='gform-field-label__text'>Description of Emergency<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_12_16' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_12_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Faculty, Administrator or Staff Verification<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_12_22'>I verify that I am a faculty or administrator recommending this student to be considered for the emergency grant\/ textbook assistance\/ laptop.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' 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