Referral Form Referral for: * ECHO (Johnston City) StarQuest Academy North (Johnston City) StarQuest Academy South (Metropolis) Student Being Referred Student ID# (from SIS) * Date of Birth * Gender * MaleFemale First Name * Middle Name * Last Name * Mailing Address * Mailing Address Mailing Address Mailing Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Mailing Address Physical Address same as Mailing Address? * Yes No Physical Address Physical Address Physical Address Physical Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Physical Address Ethnicity * American Indian/Alaskan NativeAsianBlack/African AmericanHispanic/LatinoNative Hawaiian/Pacific IslanderWhiteTwo or More Races Grade * K123456789101112 Parent/Guardian Information Parent/Guardian Name(s) * Place(s) of Work Home Phone Work Phone Cell Phone * Email Address * Basis of Referral * Primary Basis * BullyingChronic TruancyCourt/Law-Mandated ParticipationCredit DeficiencyExpulsionFailing GradesHarassmentHigh AbsenteeismHistory of RetentionInsubordinationPhysical/Emotional Health ProblemsPoor Academic PerformancePotential DropoutSocial/Emotional IssuesTardinessTruancyVandalismOther Primary Basis Additional Bases * Bullying Chronic Truancy Court/Law-Mandated Participation Credit Deficiency Expulsion Failing Grades Harassment High Absenteeism History of Retention Insubordination Physical/Emotional Health Problems Poor Academic Performance Potential Dropout Social/Emotional Issues Tardiness Truancy Vandalism OtherOther No other bases of referral Because you selected Expulsion: Please submit all documentation including acts of gross misconduct and/or disobedience which threatened the safety of other students, staff, faculty, or the school community. Expulsion Documentation Drop a file here or click to upload Choose File Maximum file size: 314.57MB Other Services Has Special Education eligibility ever been identified * Yes No 504 Plan Identified * Yes No McKinney-Vento Eligible * Yes No When was primary eligibility: What was primary eligibility: Other Services Identified Medical Referrals Other Health Food Allergies * Yes No Select Food Allergy * Peanuts Tree nuts (e.g., almonds, walnuts, cashews) Milk Eggs Wheat Soy Fish Shellfish (e.g., shrimp, crab, lobster) Sesame seeds Mustard Sulphites (often found in dried fruits, wine, and some processed foods) Lupin (a type of legume) Celery Gluten Coconut Buckwheat Molluscan shellfish (e.g., clams, mussels, oysters) Sulfur dioxide (used as a preservative) Corn Kiwi fruit Other Other Food Allergies Medical Authority Modified Meal Form * Yes No Medical Authority Modified Meal Form Drop a file here or click to upload Choose File Maximum file size: 314.57MB Academic and Behavioral Data Current Credits Earned * Total Days Suspended Interventions (RtI) /Academic and/or Behavioral * Please list services/supports Constitution Requirement Fulfilled * Yes No Reading Benchmark Date of Most Recent Reading Benchmark Grade Level Scaled Score Math Benchmark Date of Most Recent Math Benchmark Grade Level Scaled Score Total Days Enrolled * Total Days Absent * Total Days Excused * Total Days Attended * Total Days Unexcused * Has the student been referred to Truancy? * Yes No ECHO Junior High students must have a Truancy referral. Please remember to submit a referral here: https://truancy.roe21.org District Information Home School * Address Referral Made By * Position * Contact Phone * Extension Email Address * Please provide a brief and specific explanation of why you feel an alternative setting will meet the needs of the student identified above. * Upload all relevant attendance, behavior, and academic records. File Upload * Drop a file here or click to upload Choose File Maximum file size: 314.57MB To ensure the referral is reviewed thoroughly and a registration meeting can be scheduled in a timely manner, please verify that all information in the form is correct and that all necessary documentation is included. * All data is accurate and included Submit If you are human, leave this field blank.
