Greenville Public School District
District Alternative Referral Packet
____________________________
Student Name
_____________________________________
Base School
_____________________________________
Date Referred to District Alternative Review Team
Office of Operations
Revised 08.06.2012 1
Greenville Public School District
Alternative Entrance Process
Student referred to Base
School's Alternative
Education Transition
Committee
Complete Alternative
Education Transition
Committee Checklist
If recommendation is for
placement in alternative
school, complete required
documentation in District
Alternative Referral Packet
Committee reviews
documentation and makes
a recommendation
Deliver completed packet
and all required
documentation to Office
of Operations
Keep student at Base
School until written
documentation is received
of Superintendent's
Decision
Revised 08.06.2012 2
Greenville Public School District
Alternative Exit Process
Two weeks before projected
completion date, the Alternative
School's Alternative Education
Transtition Committee will complete
the Alternative Education Transition
Committee Checklist
Committee reviews documentation
with Base School 's Alternative
Education Transition Committee and
makes a recommendation
Complete required documentation
in District Alternative Referral Packet
One month after student returns to
base school, Alternative Education
Transition Committee from base and
alternative schools will meet to
review current data on student and
make a recommendation
Keep student at Alternative School
until written documentation is
received of Superintendent's
Decision
Deliver completed packet and all
required documentation to Office of
Operations
If recommendation is to return to
Alternative School, complete
required documentation in a new
District Alternative Referral Packet
Deliver completed packet and all
required documentation to Office of
Operations
Keep student at Base School until
written documentation is received of
Superintendent's Decision
Revised 08.06.2012 3
Greenville Public School District
Alternative Education Transition Committee Checklist
Student’s Name _____________________________________ MSIS # ___________________________
Referring School ____________________________ Grade _____ DOB: ____________ Age: ______
Check one: ___ Entrance Referral
___ Exit Referral
Date Completed * - Required for SPED and Regular education students
__________ Copy of RtI Folder (Entr/Exit)
__________ Counselor Referral for Alternative Education Program Form (Entr) *
__________ Parental Notification of Referral Form (Entr) *
__________ Handbook Notification Receipt (Entr) *
__________ Emergency Contact and Medical Information (Entr) *
__________ Copy of cumulative record (Entr) *
__________ Copy of recent disciplinary record from Sam7 (beg. of school year – present) (Entr/Exit) *
__________ Individual Instructional Plan (IIP) (Entr/Exit)
__________ Copy of CHOICES career plan (secondary only) (Entr)
__________ Copy of Functional Skills Assessment (Entr)
__________ Copy of recent report card (Entr/Exit) *
__________ Copy of recent attendance record from Sam7 (beg. of school year – present) (Entr/Exit) *
__________ Individual Education Plan (IEP) (if applicable) (Entr/Exit) *
__________ Copy of student’s class schedule (secondary only) (Entr) *
__________ Copy of Discovery Education Individual Student Report (Entr/Exit)
__________ Alternative Education Counselor’s notes (Exit) *
__________ List of academic grades by subject area earned while at Achievement Center (Exit) *
__________ Documentation of successful behavior as documented by behavior modification tracking
forms (Exit) *
__________ Other (example Mental Health, residential facility, etc.) *
ENTRANCE
I verify that this packet is complete and that the student’s records are ready to be reviewed by the District
Alternative Review Team.
Alternative Education Transition Committee Member Approval/Disapproval
Member
Signature Approval
Signature Disapproval
Base School Principal
Base School Counselor
Classroom Teacher
Classroom Teacher
Vocational/Technical Representative
(secondary only)
Support Staff
Transition Committee Chairperson
SPED Representative (SPED only)
Other
Revised 08.06.2012 4
Transition Committee’s Recommendation:
[ ] Refer to Achievement Center
[ ] GED
[ ] Regular Alternative
[ ] SOS
[ ] Fast Track
[ ] Other program (specify _____________ )
[ ] Retain in regular education program at base school
[ ] Retain in Special Education program at base school
[ ] Attempt other interventions at base school
Date referral packet was submitted to District Alternative Review Team _____________________
Date
==========================================================================
TO BE COMPLETED BY THE DISTRICT ALTERNATIVE REVIEW TEAM
Date referral received __________________
Received by ___________________________________
District Alternative Review Team Meeting Date________________________
Team Recommendation ________________________________________________________________
Date referred to Superintendent __________________________ (Refer to Superintendent Referral
Recommendation for Alternative Placement)
Superintendent Decision _______________________________________________________________
Date student enrolled in the Alternative School ________________ Received by __________________
EXIT
I verify that this packet is complete and that the student’s records are ready to be reviewed by the District
Alternative Review Team.
Alternative Education Transition Committee Member Approval/Disapproval
Member
Signature Approval
Signature Disapproval
Base School Principal
Alternative School Principal
Alternative School Counselor
Classroom Teacher
Classroom Teacher
Support Staff
Transition Committee Chairperson
SPED Representative (SPED only)
Other
Transition Committee’s Recommendation:
[ ] Refer to/Continue in Achievement Center
[ ] GED
[ ] Regular Alternative
[ ] SOS
Revised 08.06.2012 5
[ ] Fast Track
[ ] Other program (specify _____________ )
[ ] Retain in regular education program at base school
[ ] Retain in Special Education program at base school
[ ] Attempt other interventions at base school
Date referral packet was submitted to District Alternative Review Team _____________________
=========================================================================
TO BE COMPLETED BY THE DISTRICT ALTERNATIVE REVIEW TEAM
Date referral received __________________
Received by ___________________________________
District Alternative Review Team Meeting Date________________________
Team Recommendation ________________________________________________________________
Date referred to Superintendent __________________________ (Refer to Superintendent Referral
Recommendation for Alternative Placement)
Superintendent Decision _______________________________________________________________
Date student returned to base school ________________ Received by ___________
Revised 08.06.2012 6
Student
Referral Source
Counselor
Email
Greenville Public School District
Counselor Referral for Alternative Education Program
Grade
Age
Counselor’s History of Services
Referred to Counselor by
Date first seen by counselor
Applied Behavioral Analysis/Interventions Attempted or Initiated (include additional pages as
necessary)
Date
Specifics
Counselor’s Assessment (in Collaboration with Referring School/Teacher/Administrator)
Yes/No
Performs substantially below the performance level for pupils of the same age
Is at least one year behind in completing coursework or obtaining credits for graduation?
Is the student pregnant or a parent?
Has the student been assessed/diagnosed as chemically dependent?
If so, who determined this assessment?
Is the student a victim of physical or sexual abuse?
If so, who diagnosed this?
Has the student experienced mental health problems?
If so, who diagnosed this?
Has the student experienced homelessness within the last six months?
Does the student speak English as a second language or has limited English proficiency?
Student has been suspended, excluded, or
expelled?
YES
NO
Student has received other disciplinary
action?
YES
NO
Student has truancy issues?
YES
NO
Truancy petition filed?
YES
NO
DON’T
KNOW
Student has a social worker or case
manager?
YES
NO
Dates and explanation
Dates and explanation
Dates and explanation
Name:
Phone:
Revised 08.06.2012 7
Student has a probation officer?
YES
NO
DON’T
KNOW
Student has been in treatment?
YES
NO
DON’T
KNOW
Name:
Phone:
Facility:
Phone:
Dates Attended ________ ________ ________
________
IN-PATIENT
PATIENT
OUT-
Area
Mood/Behaviors
Description
Anxious/worried
Depressed/unhappy
Eating disorder/body image concerns
Hyperactive/inattentive
Shy/withdrawn
Aggressive behaviors
Stealing
other
Homework not turned in/not complete
Low test/assignment grades
Poor classroom performance
Sleeping in class/always tired
Sudden change in grades
Frequently tardy or absent
New student
Other
Bullying
Difficulty with family members
Illness/death in family
Parents/divorced/separated
Suspected abuse
Suspected substance abuse
Parent request
other
School Concerns
Relationships
Contact Person
Other
Are additional pages attached to this referral form? ___ Yes ___ No If so, how many pages? ___
Counselor’s Recommendation
Refer to alternative
Retain in regular education
Attempt another intervention
Revised 08.06.2012 8
_______________________________________________
Counselor’s Signature
_____________________
Date
Greenville Public School District
Emergency Contact and Medical Information
Student’s Name: ___________________________________________________________________________
Last
First
Middle
Mother’s Name: __________________________________________________
Home Phone: _______________________________
Cell Phone: _____________________________
Address: __________________________________________________________
Father’s Name: __________________________________________________
Home Phone: _______________________________
Cell Phone: _____________________________
Address: __________________________________________________________
1st Emergency Contact Person: _____________________________Relationship: __________________________
Home Phone: ______________________________
Cell Phone: _____________________________
Street Address: _________________________________________________________________________
2nd Emergency Contact Person: _____________________________Relationship: __________________________
Home Phone: ______________________________
Cell Phone: _____________________________
Street Address: _________________________________________________________________________
Physician: __________________________________________
Phone: __________________________________
Address: _____________________________________________________________________________________
Medical Problems:
______________________________________________________________________________
_____________________________________________________________________________________________
Allergies: _____________________________________________________________________________________
Daily Medications:
______________________________________________________________________________
_____________________________________________________________________________________________
Revised 08.06.2012 9
Greenville Public School District
Parental Notification of Alternative Referral Form
Date:
__________________________
To:
____________________________
Parent(s) of ______________________________
Your child has been referred for placement in an alternative education program for the following reasons:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Program placement: (check one)
___ SOS
Regular Alternative:
___ Fast Track
___ 20 days
___ GED
___ 45 days
___ Other
___ one calendar year with services at Achievement Center
The superintendent or his/her designee will be available to meet with you to discuss this matter. You will
be notified within the next 5 days of the date, time, and place of the meeting to give you and your child an
opportunity to discuss this matter.
Sincerely,
_________________________________
Principal
_________________________________
School
===========================================================================
I understand that my child _________________________________________ has been referred by
officials at his/her school for placement in an alternative education program and that I will be given an
opportunity to discuss my child’s placement with the superintendent or his/her designee. Please indicate
your preference below:
Revised 08.06.2012 10
[ ] Would like to discuss with the superintendent or his/her designee
[ ] Would not like to discuss with the superintendent or his/her designee
____________________________________________
____________
Parent Signature
Date
Greenville Public School District
Handbook Notification Receipt
I have received a copy of the School District Handbook. I understand that this handbook is to be given to
my parents or legal guardian(s) so that they may be fully informed regarding policies and procedures
regarding the school district.
______________________________________
Student Signature
_______________________________________
Date
I have read a copy of my child’s handbook that includes the district’s discipline plan.
______________________________________
Parent/Guardian Signature
______________________________________
Date
I have received a copy of the rules and regulations that address the unique needs of alternative education
program students.
______________________________________
Student Signature
_______________________________________
Date
______________________________________
Parent/Guardian Signature
______________________________________
Date
Revised 08.06.2012 11
Greenville Public School District
District Alternative Review Team Recommendation Form
Student’s Name:______________________________DOB:___________________Age:______________
School:______________________ Grade:_________ MSIS Number: ____________________________
Parent / Guardian:__________________________________________ Phone: _____________________
Address: _______________________________________
Referral Program Type: ____SOS
____Fast Track
_____GED
____Regular Alternative
Date of Meeting: _________________Time:______________ Type of Meeting: ___Entrance ___ Exit
Required Documentation: (check if documentation present)
Copy of RtI Folder
Counselor Referral for Alternative
Education Program Form
Parental Notification of Referral
Form
Emergency contact information
Documentation of medical
problems
Copy of functional skills
assessment
Alternative Education Counselor’s
notes
Copy of cumulative record
Copy of recent disciplinary record
Individual Instructional Plan (IIP)
Copy of CHOICES career plan
(secondary only)
Documentation of daily
medications
Handbook Notification Receipt
List of academic grades by subject
area
DART Member Approval/Disapproval
Member
Director of Alternative Achievement Center
Base school Principal/Designee
Alternative Achievement Center Counselor
SPED Representative (if applicable)
Director of Curriculum and Instruction
Director of Operations/Intervention Specialist
Vocational-Technical Representative(secondary
Signature Approval
Copy of recent report card
Copy of recent attendance
record
Individual Education Plan
(IEP) (if applicable)
Copy of student’s class
schedule (secondary only)
Copy of Discovery Education
Individual Student Report
Behavior Modification
tracking forms
Other:
Signature Disapproval
only)
Requires a majority decision.
Decision: (check one)
___ Student may enroll at Darling Achievement Center on _______________ (date) in
(circle one) SOS
Fast Track
GED
Regular Alternative
___ Student will continue enrollment at Darling Achievement Center in
(circle one) SOS
Fast Track
GED
Regular Alternative
___ Student may return to his or her base school on _____________________ (date).
___ Base school will attempt other intervention(s).
___ Returned to base school due to incomplete documentation.
Comments:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Revised 08.06.2012 12
_____________________________________________________________________________________
_____________________________________________________________________________________
(If necessary, attach additional notes)
Greenville Public School District
Superintendent Referral Recommendation for Alternative Placement
Student’s Name: _____________________________________________________________
Grade Level: ________________________________________________________________
Date Submitted by the District Alternative Review Team: ____________________________
Base School: ________________________________________________________________
Referring Counselor: ______________________________ Phone: ___________________
Superintendent Recommendation:
[ ] Refer to Achievement Center
[ ] GED
[ ] Regular Alternative
[ ] SOS
[ ] Fast Track
[ ] Other program (specify _____________ )
[ ] Retain in regular education program at base school
[ ] Retain in Special Education program at base school
[ ] Attempt other interventions at base school
I have reviewed data on the above mentioned student and have determined the following:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
______________________________________
Superintendent’s Signature
___________________
Date
Note: Referral recommendation adheres to local and state guidelines.
Revised 08.06.2012 13
Revised 08.06.2012 14