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NCYAA
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NCYAA RSSP Referral Form
NCYAA RSSP Referral Form
This form requires Javascript to be enabled for submission and authorization.
*
Required
You must complete all sections of this form; incomplete forms will not be processed.
Email Address of Person Completing this Referral Form
*
required
Referring Administrator Information
Referring Administrator's Name
*
required
First Name
Last Name
Referring Administrator's Email Address
*
required
Referring Administrator's Phone Number
*
required
Student Information
Student's Name
*
required
First Name
Last Name
ISBE SIS Number
*
required
Street Address
*
required
City, State, Zip Code
*
required
Home Phone
*
required
Birthdate
*
required
Must contain a date in M/D/YYYY format
Gender
*
required
Female
Male
Non-binary
Home School
*
required
Home District
*
required
Grade Level
*
required
Must contain only numbers
Ethnic Code
*
required
Eligible for Free Lunch
*
required
Yes
No
Primary Language Spoken at Home
*
required
Counselor's Name
*
required
First Name
Last Name
Counselor's Email Address
*
required
Counselor's Phone Number
*
required
Parent/Guardian #1
Parent/Guardian #1 Full Name
*
required
First Name
Last Name
Relationship to Student
*
required
Parent/Guardian #1 Email Address
*
required
Parent/Guardian #1 Primary Phone
*
required
Parent/Guardian #1 Secondary Phone
Parent/Guardian #2
Parent/Guardian #2 Full Name
*
required
First Name
Last Name
Parent/Guardian #2 Email Address
*
required
Relationship to Student
*
required
Parent/Guardian #2 Primary Phone
*
required
Parent/Guardian #2 Secondary Phone
Reason for Referral
Please indicate the specific incident(s) which prompted this referral.
*
required
0 / 1000
Please select one of the following:
Student is expelled (Expelled students must be re-enrolled and administratively transferred to NCYAA in order to participate in the program)
Student was expelled but readmitted for referral to NCYAA
Student is expulsion eligible
Student is suspended/suspension eligible
Duration of Stay: List the first semester or trimester that the student can transition to the home school. This cannot exceed two years and must be the beginning of a semester or trimester.
Example: Fall Semester 2025, 2nd Trimester Fall 2025
Eligibility Criteria for RSSP
The Illinois School Code specifies the criteria for an appropriate referral to a Safe Schools Program.
Illinois School Code 5/13A-2.5 Definition of “Disruptive Student”:
“Disruptive Student” includes suspension or expulsion eligible students in any of grades 6 through 12. Suspension or expulsion eligible students are those students that have been found to be eligible for suspension or expulsion through the discipline process established by a school district.
Which of the following is the reason for the referral.
*
required
Use of or possession with intent to use a weapon or gun
Sale and/or possession of illegal substances
Physical assault of a staff member
Chronic fighting, assault of physical violence
Arson
Theft or destruction of property of the school, staff or other students
Sexual harassment, harassment and/or hazing
Gang-related activity
Insubordination posing imminent danger to health, safety and welfare of students and staff
Repeated & willful behavior of: Flagrant or persistent disrespect, verbal assault &/or verbal threats, &/or deliberate attempts to intimidate faculty, staff, sponsors, or students. Flagrant or persistent disregard for rules & regulations of home school
Please explain.
*
required
0 / 1000
Students chronically truant from school and not exhibiting any of the above stated characteristics of “gross misconduct” are NOT eligible for services through the North Cook Young Adult Academy safe schools program.
Please list all interventions already employed by the school this year.
*
required
List specific measurable goals for the student during the placement at NCYAA (e.g, grades, attendance, behavior).
*
required
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
Yes
No
If yes, where in process is the special education case study evaluation?
Referred, but not yet tested
Completed/current, on file
Testing in progress
Refused by parent
Is the student being referred to NCYAA receiving EL services?
*
required
Yes
No
If yes, please list all EL services. NOTE: All EL services must be provided by the district.
Does the student have a 504 Plan?
*
required
Yes
No
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.
What is the first day of the current semester?
*
required
Must contain a date in M/D/YYYY format
What is the student's withdrawal date?
*
required
Must contain a date in M/D/YYYY format
Please upload the student's current report card and transcripts.
*
required
Attach up to 1 file with a maximum size of 10MB
Select File(s)
No file chosen
Community Factors
Has the student ever been involved in, or is the student currently receiving counseling/therapy in the community?
*
required
Yes
No
Has the student ever been involved with, or is this student current involved with the court system?
*
required
Yes
No
If yes, please list the reasons(s) and frequency of involvement, providing dates if available
Has the student ever been subject to, or is this student currently on supervision, probation or parole?
*
required
Yes
No
If yes, provide the name and phone number of officer in charge.
If yes, please list the reasons(s) for supervision, probation or parole, providing dates if available
Do you know if the student:
*
required
Is involved in gangs
Uses drugs
Sells drugs
Has police involvement
Has other family concerns
None of the above
Please explain.
Does the student have any medical issues that we should have knowledge of so that educational accommodations can be implemented for student success?
*
required
Yes
No
If yes, provide the name and phone number of physician.
Please provide details of condition(s).
Upload Forms
Upload a copy of all discipline records.
*
required
Attach up to 1 file with a maximum size of 10MB
Select File(s)
No file chosen
Upload a copy of certificate of health exam and medical records.
*
required
Attach up to 1 file with a maximum size of 10MB
Select File(s)
No file chosen
Upload a copy of current IEP.
Attach up to 1 file with a maximum size of 10MB
Select File(s)
No file chosen
For special education-eligible students only.
Upload a graduation requirement form.
*
required
Attach up to 1 file with a maximum size of 10MB
Select File(s)
No file chosen
Upload a standardized test score report.
*
required
Attach up to 1 file with a maximum size of 10MB
Select File(s)
No file chosen
Upload a copy of the 504 Plan, if applicable.
Attach up to 1 file with a maximum size of 10MB
Select File(s)
No file chosen
Submit
