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Gateway Success Center Application
Application will only be considered when this form is complete and all requested information is provided.
* Required
Email address
*
Your email
Student Name
*
Your answer
Student ID Number
Your answer
Gender
*
Female
Male
Date of Birth
*
MM
/
DD
/
YYYY
Current grade level
Freshman
Sophomore
Junior
Senior
Address
*
Your answer
Parent or Guardian/Relationship
*
Your answer
Phone number Home
Your answer
Cell phone number
*
Your answer
Home School
*
Your answer
Contact
Your answer
Referring Person
Your answer
Referral Date
MM
/
DD
/
YYYY
Reasons for referral
Your answer
Check all that apply
*
Parent/Pregnant
School anxiety/phobia
Impoverished
Poor impulse control
Adjudicated
Attendance issues
Prefer smaller setting
Difficulty getting along with staff
Difficulty getting along with peers
Family issues/crisis/trama
Prefer non-traditional setting
In transition (McKinney-Vento)
Anger issues
Previously dropped out
Currently not enrolled at LPS
Currently no attending school
Currently under suspension
Previous suspensions
Foster care
Title III (ESL)
ADD/ADHD
Grief Issues
504- A copy of the updated 504 is needed at the interview.
IEP- A copy of the updated IEP is needed at the interview.
Health Issues
Test Anxiety
Required
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