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A.W.A.R.E. for our Students
This is a student referral and documentation form for our students. Thank you for investing in and supporting them as a referrer, administrator, counselor, or clinician.
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* Indicates required question
Email
*
Your email
Your Name (First and Last)
Optional for Student Referrals.
Your answer
District
*
Choose
Johnson
School
*
Choose
Central Elementary School
Flat Gap Elementary School
Highland Elementary School
Porter Elementary School
W.R. Castle Elementary School
Johnson County Middle School
Johnson Central High School
Student Name (First and Last)
*
Your answer
Grade
*
Please use the following number system for these specific grades.
00 - Headstart
01 - Preschool
0 - Kindergarten
Choose
00
01
0
1
2
3
4
5
6
7
8
9
10
11
12
Age
*
Your answer
Gender
*
Choose
Male
Female
N/A
Ethnicity
*
Choose
Hispanic/Latino (01)
American Indian/Alaskan Native (02)
Asian (03)
African American/Black (04)
Native Hawaiian/Other Pacific Islander(05)
Caucasian/White (06)
2 or More Races (07)
Please provide your role
*
Choose
Parent / Guardian
Student
School Faculty / Staff
Clinician
Next
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