NEW STUDENT REFERRAL FORM

STUDENT REFERRAL FORM

Date of Referral

Referring School

Home School RCDTS Code

District #

School District Liaison

District Liaison

Phone

Title

Email Address

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

Main Email

---

The Board of Education has determined the student named below to be eligible for suspension or expulsion from school. The district further assures that the eligible student has been provided all due process and statutory rights afforded by the state and federal law and regulations, including, but not limited to the special education laws and regulations, and Section 10-22.6 of The School Code (105 ILCS 5/10-22.6).

Student Information:

First name

Middle Name

Last name

Birth Date

Gender

Grade Level

Student Identification System (SIS)#

9 Digit Number: No dashes or spaces

Eligibility for Free/Reduced Lunch

Street

City

State/Province

Zip/Postcode

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

Work Phone 1

Cell Phone 1

Email 1

Parent / Guardian 2

Relation 2

Home Phone 2

Work Phone 2

Cell Phone 2

Email 2

Referral Information

Eligible for referral due to

Referral incident(s)

If other, please specify

The semester and school year the student is eligible to return to the home school district

Is the student eligible to return early to the district based on a performance review?

Yes No Not Selected

If yes, please indicate the semester for the requested performance review.

Reviews are completed at the close of the semester selected above to determine the student's school placement for the following semester.

Special Services Information

Does the student qualify for services due to Title X or the McKinney-Vento Act status?

Yes No Not Selected

If yes, please list the Title X or the McKinney-Vento Act services the district has been or will be providing for the student.

Has a case study evaluation been completed for this student?

Yes No Not Selected

If yes, please indicate the date completed:

If yes, you MUST attach the IEP/504

Is the student currently eligible for special education services?

Yes No Not Selected

If yes, please indicate the primary area(s) of eligibility:

Secondary area(s) of eligibility?

Yes No Not Selected

If yes, please indicate the secondary area(s) of eligibility:

The student is currently eligible for other educational services (i.e. 504 plan, ESL).

Yes No Not Selected

If yes, please indicate:

Post Secondary Contact Information

Court Services

Police report made by the district due to student's referral incident.

Yes No Not Selected

Police arrest made due to student's referral incident.

Yes No Not Selected

Student is court involved due to community related incident(s).

Yes No Not Selected

If yes, please explain:

Probation officer or other court officer assigned.

Yes No Not Selected

If yes, name of court officer:

Title of court officer:

Telephone number:

Fax Number

Community Support Agencies

The student/family is involved with other community agencies and/or services.

Yes No Not Selected

If yes, please list those agencies/ contact persons:

Documentation Required

1. Completed referral form
2. District letter 1) confirming administrative transfer to ROE Alternative Program due to multiple suspensions/eligible for expulsion/ expulsion in abeyance, 2) identifying the student's disruptive behavior, and 3) date exclusion and transfer expire.
3. Course of Study Recommendation.
4. Academic transcripts.
5. Attendance / Discipline report form.
6. Disciplinary record - district detailed discipline report.
7. School physical & immunization record (6th or 9th grade).
8. Student's birth certificate.
9. Current IEP (Individualized Education Plan) as appropriate.
10. Other relevant information deemed pertinent to this referral.

District Letter (PDF ONLY)

1)Confirming administrative transfer to ROE Alternative Program due to multiple suspensions/eligible for expulsion/ expulsion in abeyance, 2) identifying the student's disruptive behavior, and 3) date exclusion and transfer expire.

Academic Transcript

Course of Study Recommendation

Please click here to download a blank copy of the Course of Recommendations form

Attendance

**********************************************

Disciplinary Record

District discipline report for the current school year, INCLUDING the referring incident.

School Physical & Immunization Records

6th or 9th grade

Student's Birth Certificate

Other relevant information deemed pertinent to this referral

ATTENDANCE/DISCIPLINE REPORT FORM

Attendance:

Please report the number of absences for the Current School Year.

Excused Absences

Unexcused Absences

Suspension Absences

Total Days Absent

Current Attendance %

Total # of Days Attended / Total # of Days Enrolled for the Current School Year.

Tardies

Class Cuts/Skipped Classes

Has a Truancy Referral to the Lake County Truancy & Attendance Division been filed?

Yes No Not Selected

DISCIPLINE

Please report the NUMBER of referrals/incidents for the Current School Year.

Alcohol:

Disorderly conduct/Disruptive behaviour:

Drugs:

Fighting:

Harassment (Non-sexual):

Insubordination:

Robbery/Theft:

Threats/Intimidation:

Vandalism:

Weapons Possession:

Violation of School Rules:

Other Offenses:

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