Base Learning Program Referral Form


Lake County Regional Office of Education Suspension Intervention Behavior, Academic, Social, and Emotional Learning for all students.

School District Liaison


The following email address will be used to send link to the application form:

Student Information

9 Digit Number: No dashes or spaces

Parent / Guardian Information

ex: Spanish

Referral Information

Special Services Information

Student Documentation Required

6th or 9th grade

District detailed discipline report

If the student will be bringing their academic materials, please provide a list of the subjects and/or assignments the student is expected to complete.

Transportation Information

The district will be responsible for transportation arrangements.

Please note the following:

"School District Liaison" and "Student Information" sections must be completed in order to "Save & Continue Later". A link to complete the referral will be sent via email to the Main Email