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

Please list medical concerns for the student. For example: any known allergies, asthma, medications taken at school, etc.

Parent / Guardian Information

ex: Spanish

Referral Information

District discipline report Describing the Referring Incident.

Academic and Special Services Information

District Liaison to answer questions regarding academic lessons and/or login issues.

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