Auglaize County Alternative School Intake Form 2021-2022
Date for Assignment must be confirmed by the Alternative School monitor in advance.
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Reason:
School Name *
Fax Number or Email for Exit Report: *
Student Name *
Grade Level *
Number of Days *
Start Date *
MM
/
DD
/
YYYY
IEP Student?
Clear selection
If yes, please list any special directions.
Will student need access to a computer? *
If yes, for what assignments?
Reminder Checklist:
Student Lunch Status *
School Official filling out form: *
Submit
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