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 Special Education Identified * Yes No 504 Plan Identified * Yes No Other Services Identified Medical Referrals Other Health Food Allergies * Yes No Medical Authority Modified Meal Form Drop a file here or click to upload Choose File Maximum file size: 314.57MB Academic Data Current Credits Earned * Total Days Suspended Interventions (RtI) * Other Constitution Requirement Fulfilled * Yes No Benchmark Progress Monitoring State Test 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 * Email Address * Please provide a brief 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 If you are human, leave this field blank. Submit
