District Referral Form | Parkland Preparatory Academy

District Referral Form

Date Referral Received *

District *

School *

Referrer Name *

First

Last

Referer Phone Number *

Additional District Contact Name

First

Last

Additional District Contact Phone Number

Student Information

Student Name *

First

Last

Date of Birth *

Age *

Grade *

Date of Last Annual Review *

Disability(s)

Related Services

Does the student have a 1:1 paraprofessional? *

Yes
No

Is this placement in lieu of expulsion? *

Yes
No

Is this placement a diagnostic or interim alternative educational setting (I.A.E.S. 45 day)? *

Yes
No

If yes, please submit current disciplinary reports, notes, Identification of Needed Assessment (domain)

Additional Student Information

Parent/Guardian Name(s) *

First

Last

Parent/Guardian Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian Phone Number(s) *

Parent/Guardian Name(s) -2

First

Last

Address -2

Address Line 1

Address Line 2

City

State

Zip Code

Phone -2

Additional Parent/Guardian Information (optional)

File Upload - Submit Current IEP

Click or drag files to this area to upload. You can upload up to 5 files.

Please submit relevant reports or documents to Parkland Preparatory Academy via this File Upload Portal.

File Upload - Submit current FBA/BIP

Click or drag files to this area to upload. You can upload up to 5 files.

Please submit relevant reports or documents to Parkland Preparatory Academy via this File Upload Portal.

File Upload - Submit Documentation of Evaluation Results, Eligibility Determination, Identification of Identification of Needed Assessments (Domain)

Click or drag files to this area to upload. You can upload up to 5 files.

Please submit relevant reports or documents to Parkland Preparatory Academy via this File Upload Portal.

File Upload - Submit Manifestation Determination, Discipline Reports

Click or drag files to this area to upload. You can upload up to 5 files.

Please submit relevant reports or documents to Parkland Preparatory Academy via this File Upload Portal.

File Upload - Submit relevant Health Records

Click or drag files to this area to upload. You can upload up to 5 files.

Please submit relevant reports or documents to Parkland Preparatory Academy via this File Upload Portal.

File Upload - If the referral is a high school student, submit a current transcript, current course grades

Click or drag files to this area to upload. You can upload up to 5 files.

Please submit relevant reports or documents to Parkland Preparatory Academy via this File Upload Portal.

File Upload - Parent consent

Click or drag files to this area to upload. You can upload up to 5 files.

Please submit relevant reports or documents to Parkland Preparatory Academy via this File Upload Portal.

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