Base Learning Program Referral Form

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

School District Liaison

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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