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North Park Academy of the Arts Check N Connect Referral Form 2018-2019
**URGENT / CRISIS / DANGER TO SELF OR OTHERS MUST BE REPORTED TO AN ADMINISTRATOR IMMEDIATELY**
Staff Name (Referred by)
Special Education Services (if yes, please contact the case-manager instead of completing this form)
Has the family been informed of your concerns?
If the family has been informed, what type of contact has been made?
ERUSD forms signed by parent/guardian
ERUSD Consent For Services
ERUSD Release of Information
Does the student have law enforcement involvement (i.e. Incarceration, Probation, or Citations)
Please describe your primary concern about this student and your reason for the referral (be specific):
Thank you for referring this student to the Check N Connect Team. Your feedback is valued. You will receive an invitation to attend an upcoming Check N Connect meeting.
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