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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**
Email address *
Student's Name *
Your answer
Staff Name (Referred by) *
Your answer
Student's Grade: *
Your answer
Services *
Required
Has the family been informed of your concerns? *
If the family has been informed, what type of contact has been made? *
Your answer
ERUSD forms signed by parent/guardian
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): *
Your answer
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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