Student Referral Process
To be completed by districts only
Please follow the steps below to submit a Student Referral to the program.
1. Call Mrs. Goedken, Principal.
If you haven’t already done so, please call Mrs. Goedken to discuss the student referral in question.
2. Documentation Required to be Uploaded.
In order to complete the referral the following information will be required for upload:
Course of Study Recommendations Form – Downloadable Form here.
School physical & immunization record (6th or 9th grade)
Student’s birth certificate
Current IEP (Individualized Education Plan) as appropriate
Other relevant information deemed pertinent to this referral3. District letter with the following information
1) confirming administrative transfer the Regional Safe School Program due to multiple suspensions/eligible for expulsion/expulsion in abeyance
2) identifying the student’s disruptive behavior
3) date of exclusion and transfer expiration date including any dates of review
4) further consequences imposed on the student if they are not successful with the program
4. Complete the Student Referral Form.
Click the link below to complete the Student Referral form. The "School District Liaison" and "Student Information" sections must be completed in order to "Save & Continue Later". A link to complete the referral will be sent via email to the District Liaison’s email address, which can then be forwarded as needed to other school staff to complete the referral.
Student Referral Form
5. Submit the Student Referral Form.
Once the referral is complete, click on the “Submit Application” button at the bottom of the page. Once submitted you will be immediately notified at the top of the page that the referral has been submitted. We will process the referral and contact you once we are ready to schedule the enrollment conference.
Please feel free to contact us with any questions/concerns at 847-872-1900. Thank you.