Candy Mountain Academy Student Referral
We are very excited about your interest in placing a student at Candy Mountain Academy!  Please complete this form to start the enrollment process.  When you have completed and submitted the form, please email cjones@esd123.org so that we may complete the process in a timely manner.
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Email *
Student Last Name *
Student First Name *
District *
Parent Name *
Parent Phone Number *
Parent Address *
Parent Email *
Referring Administrator Name *
Referring Administrator Email *
Current Teacher Name *
Current Teacher Email *
Current School *
Current Grade Level *
SSID *
Qualifying Areas *
Required
Last IEP Date *
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DD
/
YYYY
Last Eval Date *
MM
/
DD
/
YYYY
Is there a current BIP? *
Is there a current FBA? *
Number of restraints in last 3 months *
Average duration of restraints to date for last 3 months *
Number of isolations to date for last 3 months *
Average duration of isolations to date for last 3 months *
Number of suspension days to date for current school year *
Is the student on a shortened day currently? *
Is there a plan in place for transportation from their home to Candy Mountain Academy? *
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