Student Referral Form

Online Form: Student Referral Form

"*" indicates required fields

1General Information

2Home School Info

3Parents / Guardian Info

4Student Information

5Required Attachments

6Referral Reason

General Information

Referral Date*

MM slash DD slash YYYY

Preferred language in student household (if other than English)

Translator needed?

Yes

Student Name*

Birth Date*

Grade*

Referral Date*

Student Cell

Student Email

IL SIS #*

Home Address*

Street Address City ZIP Code

Home School Info

Home School*

Contact (Home School)*

Email (Home School)

Parents / Guardian Info

Parent Guardian Name #1*

First Last

Relationship to Student (Parent/Guardian #1)*

Parent Guardian Address #1*

Street Address City ZIP Code

Lives With?*

Cell Phone (Parent/Guardian #1)*

Email (Parent/Guardian #1)*

Parent Guardian Name #2*

First Last

Relationship to Student (Parent/Guardian #2)*

Parent Guardian Address #2*

Street Address City ZIP Code

Lives With?*

Cell Phone (Parent/Guardian #2)*

Email (Parent/Guardian #2)*

Student Information

Must be completed in full

Days enrolled*

Last 176 days

Excused absences*

Unexcused absences*

Days tardy*

Days suspended*

Does student have an IEP:*

Yes

Does student have a 504:*

Yes

Does student have an RTI plan:*

Yes

Is student eligible for free or reduced lunch:*

Yes

McKinney-Vento Act:*

Yes

Required Attachments to Process the Referral

Premier's Individiualized Learning Plan (ILP)*

Fill out online form

Attach downloaded form

You'll be redirected to the ILP form once you submit this form.

Premier's Individualized Learning Plan (ILP)*

Drop files here or

Max. file size: 256 MB.

Attendance data for last 176 school days

Drop files here or

Max. file size: 256 MB.

Documentation of academic, behavior & attendance interventions*

Drop files here or

Max. file size: 256 MB.

Copy of IEP, 504, RTI, Contract or Expulsion Letter (if applicable)*

Drop files here or

Max. file size: 256 MB.

Updated transcript*

Drop files here or

Max. file size: 256 MB.

Discipline records*

Drop files here or

Max. file size: 256 MB.

Current schedule & grades*

Drop files here or

Max. file size: 256 MB.

Student Removal Information

If the student is removed from Premier Academy, they will:*

Will be removed from the Home School for the remainder of the semester/school year/expulsion will go into effect

Will be removed from Premier and transfer back to Home School

Referral Reason

Referral Reason*

RSSP

TAOEP

RSSP Referral

RSSP:
Students being referred for RSSP must maintain RCDTS Home School enrollment within the district and have their RCDTS Serving School enrollment changed to 24-000-0000-00-9301. Any expelled student must be re-enrolled and administratively transferred.

Required Length of Placement*

(required for RSSP/not to exceed 2 years)

Primary Referral Reason(s)*

RSSP Suspension Eligible – student has been suspended at least twice for a period of 4-10 days for gross misconduct or involved in conduct that can be demonstrated as serious/repetitive/cumulative

PA 97-0495 RSSP Suspended & Administratively Transferred – student was suspended in excess of 20 days

RSSP Expulsion Eligible – student was expulsion-eligible due to serious/repetitive/cumulative conduct and is transferred in lieu of expulsion

PA 97-0495 RSSP Expelled & Administratively Transferred – student was expelled & administratively transferred

Secondary Referral Reason(s)*

Alcohol – liquor law violations, possession, use, sale

Disorderly Conduct – disruptive behavior

Drugs – (excluding alcohol and tobacco) – illegal drug possession, sale, use/under the influence

Fighting (mutual altercation) battery, and/or physical altercation

Harassment (nonsexual) – physical, verbal, or psychological

Insubordination – disobedience to school staff or school personnel

Robbery – taking of things by force or theft

Threats – including school threats

Vandalism – damage to school or personal property

Violation of School Rules – disobeying school rules

Weapons Possession – firearms and other weapons

Other Offenses

(must check 1 or more that corresponds with suspension or expulsion)

Please describe the other offenses

TAOEP

TAOEP:
Students must maintain RCDTS Home School enrollment within the district and have their RCTDS Serving School enrollment changed to 24-000-0000-00-9201.

Estimated Length of Placement*

Primary Referral Reason(s)*

TAOEP Chronic Truant – student who is absent w/o valid cause for 5% or more of the previous 180 regular school attendance days

TAOEP Truant – student who is absent w/o valid cause from such attendance for a school day or portion thereof

TAOEP Potential Dropout from grades 6-12 – student whose school absences or pattern of school attendance impedes the student’s learning or contributes to the student’s failure of meeting learning standards

TAOEP Dropout from grades 6-12 – student whose name has been removed from the district enrollment roster for reasons other than death, extended illness, or graduation and has not been transferred to another school

Drop Out Date*

Drop Out Reason*

Secondary Referral Reason(s)*

Credit Deficient – high school student who has not earned adequate credit for their appropriate grade level toward graduation

Court/Law Mandated – student whose participation in TAOEP has been recommended/required by law enforcement or court

Drug/Alcohol Problems – student who has been identified as having drug and/or alcohol problems

Health Problems – student having physical or emotional health conditions that place them at risk of dropping out of school

High Failure Rate - student who has failed at least 20% of academic courses in previous grade period

Low Achievement – student who falls below the district mean achievement levels in both reading & math

Low Income – a low-income student as indicated by receiving free lunch/public assistance

Tardiness – a student who comes to classes late, repetitively

Teen Parent – a student who is a teen parent and who has not received a high school diploma or GED

Other Offenses

Please describe the other offenses

Truancy Interventions/Services*

Student conference with Counselor/Dean/Administrator

Parent conference with School Administrator

Phone calls to parent/guardian

Referral to outside social services agencies

School Nurse

Home visits

Issued Med Doc form

Social Work services

(check all that apply)

Please check the following documents that have been utilized and included with this referral:*

1st attendance letter

2nd attendance letter with medical documentation

3rd attendance letter

Officer Name

Student Referral Form

Online Form: Student Referral Form

General Information

Home School Info

Parents / Guardian Info

Student Information

Required Attachments to Process the Referral

Student Removal Information

Referral Reason

RSSP Referral

TAOEP

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