NCYAA RSSP Referral Form

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

Email Address of Person Completing this Referral Formrequired

Referring Administrator Information

Referring Administrator's Namerequired

First Name

Last Name

Referring Administrator's Email Addressrequired

Referring Administrator's Phone Numberrequired

Student Information

Student's Namerequired

First Name

Last Name

ISBE SIS Numberrequired

Street Addressrequired

City, State, Zip Coderequired

Home Phonerequired

Birthdaterequired

Must contain a date in MM/DD/YYYY format

Genderrequired

Female

Male

Non-binary

Home Schoolrequired

Home Districtrequired

Grade Levelrequired

Must contain only numbers

Ethnic Code

Eligible for Free Lunchrequired

Yes

No

Primary Language Spoken at Homerequired

Counselor's Namerequired

First Name

Last Name

Counselor's Email Addressrequired

Counselor's Phone Numberrequired

Parent/Guardian #1

Parent/Guardian #1 Full Namerequired

First Name

Last Name

Relationship to Studentrequired

Parent/Guardian #1 Email Addressrequired

Parent/Guardian #1 Primary Phonerequired

Parent/Guardian #1 Secondary Phone

Parent/Guardian #2

Parent/Guardian #2 Full Namerequired

First Name

Last Name

Parent/Guardian #2 Email Addressrequired

Relationship to Studentrequired

Parent/Guardian #2 Primary Phonerequired

Parent/Guardian #2 Secondary Phone

Reason for Referral

Please indicate the specific incident(s) which prompted this referral.required0 / 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.

The student's return day is the first day of the semester

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.

Please explain. required0 / 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. Please be as specific as possible.required

List specific measurable academic goals for the student during the placement at NCYAA. (i.e. Student must maintain a 2.0 GPA throughout placement.)required

List specific measurable attendance goals for the student during the placement at NCYAA. (i.e. Student must maintain 90% attendance throughout placement.)required

List specific measurable behavioral goals for the student during the placement at NCYAA. (i.e. Student must not have and tier 3 infractions throughout placement.)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 MM/DD/YYYY format

What is the student's withdrawal date?required

Must contain a date in MM/DD/YYYY format

Please upload the student's current report card and transcripts.required

Attach up to 1 file with a maximum size of 10MB

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

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 student discipline records.required

Attach up to 1 file with a maximum size of 10MB

No file chosen

Upload suspension letters, expulsion documents, or expulsion abeyance documents related to the incident.required

Attach up to 1 file with a maximum size of 10MB

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

No file chosen

Upload a copy of current IEP.

Attach up to 1 file with a maximum size of 10MB

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

No file chosen

Upload a standardized test score report. required

Attach up to 1 file with a maximum size of 10MB

No file chosen

Upload a copy of the 504 Plan, if applicable.

Attach up to 1 file with a maximum size of 10MB

No file chosen

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In This Section

NCYAA RSSP Referral Form

Referring Administrator Information

Student Information

Parent/Guardian #1

Parent/Guardian #2

Reason for Referral

Eligibility Criteria for RSSP

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.

Special Education Services

Academic Information

Community Factors

Upload Forms

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