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NCYAA On-Site ALOP Referral Form

Required

You must complete all sections of this form; incomplete forms will not be processed. 

Referring Administrator Information

Referring Administrator's Namerequired
First Name
Last Name

Student Information

Student's Namerequired
First Name
Last Name
Must contain a date in M/D/YYYY format
Genderrequired
Must contain only numbers
Eligible for Free Lunchrequired
Counselor's Namerequired
First Name
Last Name

Parent/Guardian #1

Parent/Guardian #1 Full Namerequired
First Name
Last Name

Parent/Guardian #2

Parent/Guardian #2 Full Namerequired
First Name
Last Name

Reason for Referral

0 / 1000

Eligibility Criteria for On-Site ALOP

Which of the following is the reason for the referral?requiredPlease select up to 4 choices
Please select up to 4 choices
0 / 1000

Special Education Services

NOTE: If a student who is eligible for special education services is accepted into the NCYAA program, the home school district will remain fully responsible (including financially) for the provision of any and all prescribed special education services. North Cook Young Adult Academy staff must be invited to all MDC, IEP, and annual review conferences, including the pre placement conference, which may recommend placement in the NCYAA program.
Is the student being referred to NCYAA eligible for, or currently receiving, special education services?required
If yes, where in process is the special education case study evaluation?
Is the student being referred to NCYAA receiving EL services?required
Does the student have a 504 Plan?required

Academic Information

Please list the courses in which the student is/was enrolled for the current semester. Then list the grades the student is/was earning in each of the courses from the first day of this semester until the withdrawal date.
Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format
Attach up to 1 file with a maximum size of 10MB
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Community Factors

Has the student ever been involved in, or is the student currently receiving counseling/therapy in the community?required
Has the student ever been involved with, or is this student current involved with the court system?required
Has the student ever been subject to, or is this student currently on supervision, probation or parole?required
Do you know if the student:required
Does the student have any medical issues that we should have knowledge of so that educational accommodations can be implemented for student success?required

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For special education-eligible students only.
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