<p> ALTERNATIVE SCHOOL REFERRAL FORM</p><p>Student’s Name Phone # DOB </p><p>Referring School </p><p>Is this student currently receiving special education services? Yes No</p><p>If yes, attach a copy of the IEP. Has the IEP been amended to reflect the Alternative School Placement? *Yes No</p><p>Case Manager Disability Code </p><p>Is this student currently on a 504 or ELL Plan? Yes No</p><p>If yes, attach a copy of the 504 or ELL Plan. 504 Contact </p><p>Is the student currently taking medication? Yes No </p><p>If yes, please list the medications </p><p>Date of Assignment to the Alternative School </p><p>Length of Assignment to the Alternative School </p><p>Date of Return to Base School </p><p>Transportation Parent Bus</p><p>For Administrator of Assignment School – Copies of this form have been sent to the following personnel (list names): </p><p>Classroom Teacher(s) </p><p>Counselor </p><p>Special Ed. Case Manager </p><p>Registrar and/or Attendance Clerk </p><p>Administrator Completing this Form </p><p>Date Sent </p><p>* Reminder: Amended IEP must be attached to this form and sent to the Alternative School.</p>