New Base Learning Program Referral Form

Base Learning Program Referral Form

---

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

Date of Referral

Referring School

District #

School District Liaison

District Liaison

Phone

Title

Email Address

---

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

Student Information

First Name

Last Name

Birth Date

Gender

Grade in School

Student Identification System (SIS)#

9 Digit Number: No dashes or spaces

Street

City

State/Province

Zip/Postcode

Medical Information

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

Does Student Qualify For Free/Reduced Lunch

Yes No Not Selected

Parent / Guardian Information

Translation Required ?

Yes No Not Selected

If yes, please type language

ex: Spanish

Students Live With

Parent / Guardian 1

Relation 1

Home Phone 1

Cell Phone 1

Email 1

Parent / Guardian 2

Relation 2

Home Phone 2

Cell Phone 2

Email 2

Emergency Contact Information

Referral Information

Projected Start Date of Placement

Projected End Date of Placement

Suspension Intervention Reason:

Other Suspension Reason (Describe):

BASE Disciplinary Record

District discipline report Describing the Referring Incident.

Academic and Special Services Information

Academic Contact Information

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

Is the student currently receiving any special education services and/or accommodations?

Yes No Not Selected

If yes, please list any accommodations the student will require while attending BASE.

Transportation Information

The district will be responsible for transportation arrangements.

Transportation Provider

Transportation Phone Number

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