Haysville Alternative High School Referral Form 2009-2010
     
     

    Student’s Name:____________________________________________________
     
    Date:_____________________________________________________________
     

         
    Yes No 1. I am a special education or 504 student who is currently attending Campus High School.
    Yes No 2. I am currently failing classes at Campus High School. Days absent____
    Yes No 3. I have less credits than other students at my grade level.
    Credits completed ___________
    Step 1: See Special Education Department Head for this form.
    Step 2: Get a signature from YOUR counselor.__________________________________

    A counselor who signs this from says in doing so that he or she believes that this student be best served at Haysville Alternative High School.
     
    Step 3: Get the signature of YOUR principal:___________________________________
     
    A principal who signs this form says in doing so that he or she believes that this student would benefit from being educated at Haysville Alternative High School.
     
    Step 4: Get the signature of YOUR parent or guardian:___________________________
     
    A parent or guardian says, “Yes, I want my student considered for placement at HAHS.”
     
    Step 5: Return this form to Sp. Ed. Dept. Head: She will sign it and YOU will sign it. By signing this form YOU are authorizing Sp. Ed. Dept. Head to contact Mr. Regier and Mr. Foster to set up interviews to consider your potential transfer to HAHS.
     
    _____________________________________  ______________________________
    Student Date    Sp. Ed. Dept. Head     Date
     
    Step 6: Your interview with Mr. Regier is scheduled for: _________________________
     
    Step 7: Your interview with Mr. Foster is scheduled for: __________________________
     
    Step 8: Your placement is APPROVED or DISAPPROVED
     
    Step 9: Your IEP is scheduled for: ___________________________________________
     

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