Auglaize County Alternative School Intake Form
(Date for assignment must be confirmed by the Alternative School monitor in advance)
School District: *
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Fax Number: *
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Student Name: *
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Grade:
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Number of days assigned:
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Start Date: *
MM
/
DD
/
YYYY
Reason for assignment:
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IEP Student?
If yes, please list any special directions.
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Will student need access to a computer?
If yes, what assignment will technology be used for?
Your answer
Reminder Checklist:
Student Lunch status. *
School Official filling out form: *
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