Northdale Magnet Application

East Baton Rouge Parish Alternative School Referral Form

2008-09

Student Name _______________________________________ Date of Birth__________

Parent/Guardian__________________________________________________________

Phone Numbers (home)______________(work)______________ (cell)______________

Home Address ___________________________________________________________

Current or most recently attended school ______________________________________

Regular Education ______ Exceptional Student ______ Exceptionality ______________

Entering Grade:  9  10  11  12                     Number of Credits Earned ________________

                            (circle one)

Summary of Student’s Strengths and Weaknesses:_______________________________

At Risk Characteristic(s): Check one or more

___ Excessive Tardiness and/or Absenteeism   ___ Behavior Problems   ___ Drop Out

___ Failure of one or more school years   ___ Performance consistently below potential

___ Lack of participation in extra-curricular activities ___ Substance Abuse 

________________________________________________________________________

The following must be attached to application:___ Discipline Report  ___ Report Card

___ Attendance Report   ___ Current Transcript ___ State Test Results ___ IEP/504

___ Copy of Social Security Card ___ Proof of Residency

_____________________________                     ________________________________

Referral Signature                                                       Parental Approval (to release records)