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SY25 Referral for Virtual Academy Program
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Referral for Virtual Academy Program

Some students with medical conditions learn best in a virtual learning environment. In these unique instances, students may be enrolled for the school year at The Virtual Academy.  The Virtual Academy is a full-day instructional program that lasts 1 school year and is fully virtual with classes taught by CPS teachers.  Please complete this form for your student/patient who may meet these distinctive conditions. Based upon the Virtual Academy’s capacity, accepted students will receive a full day of virtual instruction by CPS teachers if deemed necessary by a licensed medical professional.  

Students are required to attend a full school day from 8:30 - 3:30 pm.  When students transition back to in-person, they will be returned to their most recent CPS school.  In CPS systems, accepted students will be primarily enrolled in the Virtual Academy Program and their physical school will be their secondary enrollment.

Questions should be directed to  

All applicants should review the program overview & requirements which can be accessed via this QR Code:

Spanish Version of Referral//Versión en español de la remisión

STUDENT INFORMATION (completed by the parent)

Student’s Name______________________________________________________  Date of Birth___________________

CPS School Name_____________________________ CPS ID#_________________________    Current Grade___________

Parent/Guardian Information:

Name of Parent/Guardian______________________________________________________________________

Email_____________________________________________ Phone _____________________________________________

Parent Signature affirming wish to enroll the student in the Virtual Academy and agreement that student will engage for a full school day of classes.   _______________________________________________

Section To be Completed by a Medical Professional (physician licensed to practice medicine in all of its branches, licensed physician's assistant, or licensed advanced practice nurse):

 STUDENT ELIGIBILITY (completed by a Medical Professional )

Date of most recent medical examination ____________________________________________________________________________________________________

Diagnosis(s) that negatively impacts student’s ability to attend in-person school: _____________________________________________________________________________________________________________

Pertinent information which includes how the student’s medical/psychiatric condition affects the student’s ability to attend school in person_________________________________________________________________________________________________________________________________________________________________________________ 

Specify ongoing treatment and/or interventions for the condition that precludes the student’s attendance for in-person school


What format of learning best serves the student based on medical needs? (Circle One)

Daily in-person learning at a physical school                 OR         Daily Virtual Learning

Specify all recommendations on why virtual or in-person learning best serves the student.

_________________________________________________________________________________________________________________________________________________________________________________________________________________________Medical Professional INFORMATION 

Physician’s Complete Name (Print) ___________________________________________Physician’s NPI _________________________  Physician’s Specialty (area of practice)______________________________________________________________________________ Phone________________________Physician’s E-Mail________________________________  Hospital(s) Affiliation(s)_________________________________________

Physician’s Signature_________________________________________________________ Date ___________________

Next Steps: