Referral Form for Enrollment of Current SLCS Student in Graduation Alliance

Definition: A student with a current SLCS schedule who informs their administrator or counselor that they wish to drop out of school.

Student Name Date SLHS or SLEHS

Home Phone Number Parent or Guardian Name

Student’s Address Grade

To be completed by Administrator: Check with Mariann Martin: YES YES Has the district already received a foundation allowance for the student Student needs to continue in the school until If eligible for 23A funding and meeting this school year? the end of the year, but would be eligible for other criteria, student could begin GA GA using 23A funding the following year. program In extenuating circumstances, the school may opt to pay the enrollment costs out of building funds. Check with Sue Toth: YES NO Does the student have a 504 or an IEP? The student may be able to enroll in GA but If the student meets other criteria, GA would need Sue’s approval to ensure that the enrollment is an option. required accommodations or services could still be implemented through GA. At this point, provide Sue with the academic record to help her make a determination. Check student record with counselor: YES NO Does the record indicate this student is likely to benefit from and be successful Counselor and administrator concur that the Counselor and administrator feel in this program? student is a good candidate for GA. student is not a good fit for GA and discuss other options available with the student.

0b2e8115b9403cb0ebd1846a1f6c2625.docx - Updated Jun. 8, 18 - Page 1 of 2 Determination: ____ Student is a good candidate for Graduation Alliance- paid with 23A funds. ____ Student is a good candidate for Graduation Alliance- paid with building funds. ____ Student is a good candidate for Graduation Alliance, but is not eligible to begin until 23A funding becomes in July. ____ Student is not a good candidate for Graduation Alliance due to the following reason: ______

Preparer Signature : Date

If student has a 504 or an IEP, Sue Toth must also approve the enrollment:

Approved Denied

Special Ed. Director Signature: Date

Final Decision:

Approved Denied

Principal Signature: Date

Next steps: Retain original copy in student file and send copies to 1. Copy to Mariann Martin 2. Copy to Lisa Kudwa

If the student has a 504 plan or an IEP 1. Print a copy for Special Education Director 2. Determine if the plan needs to be updated or amended

Share decision with Graduation Alliance.