Referral Form

Crossroads Application Referral Form

3350 Commercial Drive, Suite 101

Anchorage, AK 99501

Phone: 742-2424 Fax: 742-2425

 

 

Thank you for considering Crossroads School.  We accept female students that are pregnant and/or parenting.  When submitting this application, please include the student’s current transcript, health and discipline records, special education/504 records, grades to date, verification of pregnancy from a doctor or a birth certificate if parenting. The student and her parent(s) or guardian(s) must attend an interview and turn in all paperwork prior to enrollment.  The interview process is to make sure that Crossroads can meet the needs of the applicant, and the applicant can make sure Crossroads is a good fit for her.  Crossroads will contact the applicant regarding acceptance into the program ASAP.

 

 

Student Name_____________________________________________

ID Number_______________________

Age_________ Birth Date ______/_______/______ Grade_________ 

Credits Earned___________________

Is student currently enrolled? _______________

Where?___________________________________________

ASD School Zone in Which Student Lives______________________________________

ASD Counselor __________________________________________________________

Mother/Guardian_________________________________________

Work Phone________________________

Father/Guardian__________________________________________

Work Phone_______________________

With Whom Does the Student Live?___________________________________________

Address___________________________________________________

Home Phone_____________________

Student Cell__________________ Mother Cell __________________

Father Cell ________________________

 

Other Programs the student has participated in:

CIT______ AMYA______ Migrant Ed______ Bilingual_______ MYC _______

Probation ______             Step Up _______            Inpatient______            Outpatient______

 

Special Education:

Has the student ever received any assistance through special education? Yes____ No____

Is the student being considered for special education?  Yes____ No____

Does the student have a current IEP?  Yes____ No____  If so, please include a copy.

Date of most recent three-year evaluation_______________________________________

Does the student have a current 504 Plan?  Yes____ No____  If so, please include a copy.

Did the IEP team consider placement in regular education classes with ONLY study skills help?  Yes____ No____

 

Academics: List classes in progress and grades to date

1.________________________________                                2.________________________________

3.________________________________                                4.________________________________

5.________________________________                                6.________________________________

 

Transportation: 

The only transportation provided to Crossroads is from King Career Center.  The student or parent must provide the student’s transportation to and from school.

What are the student’s transportation plans?______________________________________

 

Please provide any other information that will help us with this student.

__________________________________________________________________________

 

Other Relevant Information (Optional):

 

Medication, if any______________________________

Allergies______________________________________

Drug/alcohol problems__________________________

Residential treatment___________________________

Outpatient treatment___________________________

Name of agency________________________________

Therapist/Counselor_____________________________

Social Worker__________________________________

Probation officer _______________________________

Family Issues, Be Specific____________________________________________________

_________________________________________________________________________

Emotional Issues____________________________________________________________

Peer Problems______________________________________________________________

Other/Comments:___________________________________________________________

 

Name of Referrer (Please Print) ________________________________________________

Title______________________________________________________________________

 

______________________________________________     _________________________

Counselor/Administrator Signature                                                         Date

 

______________________________________________      _________________________

Special Education Department Chair Signature                                       Date

 

______________________________________________      _________________________

Parent Signature                                                                                    Date