Alternative School Referral Form

ALTERNATIVE SCHOOL REFERRAL FORM

Student’s Name Phone # DOB

Referring School

Is this student currently receiving special education services? Yes No

If yes, attach a copy of the IEP. Has the IEP been amended to reflect the Alternative School Placement? *Yes No

Case Manager Disability Code

Is this student currently on a 504 or ELL Plan? Yes No

If yes, attach a copy of the 504 or ELL Plan. 504 Contact

Is the student currently taking medication? Yes No

If yes, please list the medications

Date of Assignment to the Alternative School

Length of Assignment to the Alternative School

Date of Return to Base School

Transportation Parent Bus

For Administrator of Assignment School – Copies of this form have been sent to the following personnel (list names):

Classroom Teacher(s)

Counselor

Special Ed. Case Manager

Registrar and/or Attendance Clerk

Administrator Completing this Form

Date Sent

* Reminder: Amended IEP must be attached to this form and sent to the Alternative School.