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Umoja Scholar Referral Form – Connecting Students to Culture, Community & Support
Umoja Scholar Referral Form – Connecting Students to Culture, Community & Support
Section 1: Referrer Information
Your Name (Faculty/Staff)
Email Address
Section 2: Student Information
Student's Full Name
Student’s ID Number (if known)
Section 3: Reason for Referral
Why are you referring this student to the Umoja Program? (Select all that apply):
Cultural connection & sense of belonging
Academic support or tutoring
Mentoring or guidance
Community engagement / student involvement
Support navigating college resources or systems
Personal motivation or confidence-building
Early alert concern
Other (please describe)
Key Concern/Strength:
(Quick note on why you're referring them)
How urgent is this referral?
High: Please contact the student as soon as possible
Moderate: Contact within the next two weeks
Low: Contact when able
Section 4: Referrer Notes
Have you already spoken with the student about the Umoja Program?
Yes, the student is interested
Yes, but I’m not sure if they’re interested
No, I have not spoken with the student yet
Additional comments you would like Umoja staff to know:
Section 5: Consent
Do you give permission for Umoja staff to use your name when contacting the student?
Yes
No
Submit
