Referral for Alternative Program Placement Office of School Support and Improvement

Referral for Alternative Program Placement
Office of School Support and Improvement
MONTGOMERY COUNTY PUBLIC SCHOOLS
Rockville, Maryland 20850
MCPS Form 336-55
October 2014
Page 1 of 3
Directions:
1. School staff complete referral packet and submit completed packet to assigned PPW.
2. PPW from the referring school submits completed packets to:
Principal, Alternative Programs (AP), 14501 Avery Rd., Rockville, 20853
Student Information
Name ID Number Age Sex Grade Credits Date of Birth Days Absent (current year)
Referring School GPA (current
/
/
)
Home/Base School School Staff Contact Person/Position Contact Person Phone Number -
-
Parent/guardian Information
Name Name Relationship Relationship Address
Address
Street
Street
City
State
ZIP Code
E-mail address
City
State
E-mail address
Home Phone
-
-
Home Phone
-
-
Work Phone
-
-
Work Phone
-
-
Cell Phone
-
-
Cell Phone
-
-
Student lives with: q Mother ZIP Code
q Father q Both
q Other (specify) Free or Reduced Lunch q Yes q No Language spoken at home Interpreter Requested: q Yes q No
Involvement of Other Agencies/Professional Support
Agency Contact Person Address
Street
Phone City
-
State
ZIP Code
Involvement of Other Agencies/Professional Support
Agency Address
Street
Contact Person Phone City
State
DISTRIBUTION: COPY 1/Principal, Alternative Programs; COPY 2/Referring School Principal; COPY 3/Referring School PPW
-
ZIP Code
Referral for Alternative Program Placement
Office of School Support and Improvement
MONTGOMERY COUNTY PUBLIC SCHOOLS
Rockville, Maryland 20850
MCPS Form 336-55
October 2014
Page 2 of 3
SENDING SCHOOLS INTERVENTIONS: Please attach the following:
q Level 1 alternative teacher reports/notes
q School Meeting Notes: including parent conferences, EMT/CAP, IEP
q Consultation
q Evaluation(s)
q Individualized Education Program (IEP)
q Section 504 Plan
q Referrals to other educational departments/outside agencies
q Outside agency reports/letters (e.g. medical, psychiatric)
Behavior
q Referrals for Disciplinary Action, including in-school suspension (i.e., OASIS suspension data, SWIS data)
q Communication Logs
q Anecdotal Records
q Suspension Letters
q Functional Behavioral Assessment (FBA)
q Behavior Intervention Plan (BIP), including any contracts
Academic
q Current teacher reports (including Alternative 1 teacher)
q Transcript (SRS 2 Card)
q Report Cards
q Test Data
Attendance
q SR 1 card
q Current Attendance Printout
Health
q Immunization record
q School Health Plan
q Identify Other Areas of Concern
Referral (Include Date Of Referral)
Date
Referral initiated by:
q Educational Management Team
q Chief Operating Officer
q Expulsion Review Board
q Other: DISTRIBUTION: COPY 1/Principal, Alternative Programs; COPY 2/Referring School Principal; COPY 3/Referring School PPW
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Referral for Alternative Program Placement
Office of School Support and Improvement
MONTGOMERY COUNTY PUBLIC SCHOOLS
Rockville, Maryland 20850
MCPS Form 336-55
October 2014
Page 3 of 3
Reason For Referral
Suggested Areas to be included in Personal Learning Plan Goals
1.____________________________________________________________________________________________________________________
2.____________________________________________________________________________________________________________________
3.____________________________________________________________________________________________________________________
Special Considerations
q Restrictions placed as the result of disciplinary action (attach letter from Chief Operating Officer or DPPS)
)
q ESOL (Level
q Special Education: q Yes q No
If yes, disability code and services
q Section 504 Plan: q Yes q No
q Recommended supports needed___________________________________________________________________________________
q Other (specify): Signatures (Required)
I have been informed that my child is being referred to Alternative Programs placement.
Signature, Parent/Guardian
Signature, Pupil Personnel Worker (from referring school)
Signature, Principal
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Date
Date
Date
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Submit all completed packets to: Alternative Programs Admissions Committee, Alternative Programs (AP), 14501 Avery Rd., Rockville, 20853.
DISTRIBUTION: COPY 1/Principal, Alternative Programs; COPY 2/Referring School Principal; COPY 3/Referring School PPW