Rogers Public Schools
To provide an environment of education excellence where all belong, all learn, and
Alternative Learning Environment (ALE)
Student Referral Packet
Student Name
Student ID#
Referring School
Previously assigned/attended an ALE program.
Proof of attendance in an ALE program attached.
ALE Destination:
Crossroads HS
all succeed.
Note that if a student is reported to
have previously attended an ALE
program and the parent can present
proof of attendance in an ALE program,
we can expedite the process. Check
only the box to the left, indicate ALE
destination and send the packet, along
with proof of attendance in an ALE
program, to The Annex, to the attention
of the principal. For all other students,
the data collection of the formal referral
process must be followed.
Crossroads MS
Extended Day
The items in italics are required documents/information. Please write 'NA' on the items that are not
applicable:
Discipline records
SpEd
504 Plan
Attendance Records
Credit Check Sheet and/or grades
AIP
Placement Committee Referral Form
Committee must fill out both pages
RTI documentation
Parental agreement form (last page)
_______
Working phone number for the
parent/guardian
Interpreter needed
( yes / no)
IEP Modifications
The district does not support moving
students to indirect services in order to
be transferred to an ALE location. For
SpEd students, documentation of the
separate programming and placement
must be attached.
ELL level
The district does not support transferring
an ELL1 and generally an ELL2 to an
ALE location except under special
circumstances.
(Person initiating process/title)
(Counselor signature)
(Building principal signature)
(Parent signature)
Student Signature
Below this line for ALE use only
Date complete packet received
Parent/Student Intake Conference date/time
ALE Principal’s Signature
Revised 091409, 041113, 052813
1
Confidential
Placement Committee Referral Form
Student Name:
Date:
4.00 Special Needs - Alternative Learning Environment (ALE)
4.01
Eligible ALE Students
4.01.1
An eligible ALE student shall exhibit two (2) or more of the characteristics identified in
4.01.1.1 and 4.01.1.2. Students will not be placed in the ALE based on academic
problems alone.
4.01.1.1 Students placed at risk, though intelligent and capable, typically manifest one or more
of the following characteristics:
Please mark all items that apply to the student and explain below: You must mark at
least one item.
Disruptive behavior
Drop out from school
Personal or family problems or situations
Recurring absenteeism
Transition to or from residential programs
4.01.1.2 Situations that negatively affect the student’s academic and social progress may
include, but are not limited to:
Please mark all items that apply to the student and explain below: You must mark at
least one item.
Ongoing, persistent lack of attaining proficiency levels in literacy and
mathematics
Abuse: physical, mental, or sexual
Frequent relocation of residency
Homelessness
Inadequate emotional support
Mental/physical health problems
Pregnancy
Single parenting
Comments:
Administrator
Revised 091409, 041113, 052813
Counselor
Teacher
2
Confidential
Placement Committee Referral Form page 2
Student Name:
Date:
4.01.1 An eligible ALE student shall exhibit two (2) or more of the characteristics identified in 4.01.1.1
and 4.01.1.2. Students will not be placed in the ALE based on academic problems alone.
Please mark all items that apply to the student and explain below:
ACADEMIC PERFORMANCE
Overly motivated to achieve
Is achieving on par with test scores
Achieving below potential
Recent decline in quality of work
Sporadic performance
Attitude affecting work
ATTENDANCE
Frequently absent
Frequently suspended
Frequently tardy
Cuts classes and/or has been truant
_____
Dropout
PEER RELATIONSHIPS
Positive support peer group
Withdrawn/isolated
Fighting
Threatening/intimidating
Sudden change in peers
Assumes “victim” role
Associated with negative peer group
OTHER RISK FACTORS
Past suicide gesture/attempt
Talks of suicide
Dramatic attention seeking behavior
Depressed/flat affect
Neglects physical appearance & needs
Voices sense of hopelessness
Suspected gang involvement
Suspected abuse of student: physical,
mental, sexual (circle)
Personal illness
Illness/death in the family
Judicial issues
Frequent relocation / mobility / homeless
Demonstrates behaviors associated with
alcohol/drug use
Transition from Residential Program
Has run away
Student is pregnant
Student is a single parent
Student is not living with parents
Summary paragraph explaining why the student should be considered for an ALE setting:
Administrator
Revised 091409, 041113, 052813
Counselor
Teacher
3
Rogers Public Schools
To provide an environment of education
excellence where all belong, all learn, and
all succeed.
The Annex
Crossroads Alternative High School
Crossroads Alternative Middle School
Extended Day Alternative High School
Therapeutic Day
2922 S. 1st Street
Rogers,
AR 72758

http://www.rogersschools.net/
(479)
631-3690

Program
Program
Program
Program
FAX (479) 631-3570
Cindy Ford, Principal
Linda Haley, Counselor
Re: Parental agreement
Dear parent/guardian:
A placement in alternative education is a partnership between the student, the parent/guardian
and the school personnel. As part of our agreement, we will be ready for your student. We will
be respectful of your concerns as well as of your student’s needs, and we will be responsible for
providing the best possible academic experience for your student. In return, we ask that you
work with us and be an engaged parent. Specific things we need from you are:
 Your attendance at orientation so that you will learn about the expectations of our
program
 Your attendance at fall and spring parent/teacher conferences
 Your cooperation and support.
Sincerely,
Cindy Ford, Principal
*****************************************************************
Parent/guardian, please sign:
My signature below indicates that the person initiating the referral process has had a
conversation with me and that I am in agreement with my student being considered for potential
placement at Crossroads or Extended Day.
(parent/guardian signature)
Revised 091409, 041113, 052813
(date)
4