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Referral Form to Alpha Program
Brewer High School Alternative Education Program

Referrals for Alpha are electronically submitted to the Student Success Team (SST).

Email address *
Person making Referral *
Required
Relationship to student *
Required
Is the student aware of this referral to consider placement at Alpha? *
Date of Referral *
MM
/
DD
/
YYYY
Student Name *
Date of Birth/Age *
Current Grade *
Gender: *
Parent/Guardian Name and Address *
Cell Phone/Home Phone *
Work Phone *
Is the student experiencing homelessness or is he/she an unaccompanied youth (McKinney-Vento)? *
Rationale for requesting Alpha: check all that apply. *
Required
Additional Information / Explanation of Need for Alpha: *
A copy of your responses will be emailed to the address you provided.
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