STUDENT REFERRAL FORM

School District Liaison

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

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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:


9 Digit Number: No dashes or spaces

Parent/Guardian Information:


ex: Spanish

Referral Information

Special Services Information

Court Services

Community Support Agencies

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 Recommendations.
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.


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.

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District detailed discipline report

6th or 9th grade

ATTENDANCE/DISCIPLINE REPORT FORM

Attendance:

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

DISCIPLINE

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

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