District Referral Form Please enable JavaScript in your browser to complete this form.Date Referral Received *District *School *Referrer Name *FirstLastReferer Phone Number *Additional District Contact NameFirstLastAdditional District Contact Phone NumberStudent InformationStudent Name *FirstLastDate of Birth *Age *Grade *Date of Last Annual Review *Disability(s)Related ServicesDoes the student have a 1:1 paraprofessional? *YesNoIs this placement in lieu of expulsion? *YesNoIf yes, what is the expulsion ending date? (If yes, please submit any Manifestation Determination and Disciplinary reports)Is this placement a diagnostic or interim alternative educational setting (I.A.E.S. 45 day)? *YesNoIf yes, please submit current disciplinary reports, notes, Identification of Needed Assessment (domain)Additional Student InformationParent/Guardian Name(s) *FirstLastParent/Guardian Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeParent/Guardian Phone Number(s) *Parent/Guardian Name(s) -2FirstLastAddress -2Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone -2Additional 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.WebsiteSubmit