AAAC Referral Form (AHS)
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Student Information
Student's FIRST Name *
Student's LAST Name *
Grade *
Age *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Social Security # *
### - ### - ####
Student ID # *
Race *
Street Address *
City *
Zip Code *
Student's Home Phone
( ###) ### - ####
Student's Cell Phone
( ###) ### - ####
Parent Information
Mother's Full Name
Mother's Address
Mother's City
Mother's Zip Code
Mother's Home Phone
( ###) ### - ####
Mother's Cell Phone
( ###) ### - ####
Mother's Employer
Father's Full Name
Father's Address
Father's City
Father's Zip Code
Father's Home Phone
( ###) ### - ####
Father's Cell Phone
Father's Employer
Referral Details
Reason for Referral *
Referral Requested By *
Referral Requested By (First & Last Name) *
Referral Requested By (Email Address) *
Required Documentation
Please include the following documentation:
• Transcript
• Discipline record
• Test Scores (updated TAKS/EOC CSR)
• Attendance Records
• TELPAS scores (if applicable)
• Doctor’s form (if applicable)
• Special Education or 504 information (if applicable)
If the student is in Special Education, include diagnostician form

English I EOC Score
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English II EOC Score
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Biology EOC Score
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Algebra I EOC Score
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US History EOC Score
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Principal Recommendation
It is imperative to the evaluation of the student's application that the principal completes this section. Failure to do so will delay the process. Please be candid in your remarks.
Principal FULL Name *
Principal Email Address *
Principal Remarks:
Counselor Recommendation
It is imperative to the evaluation of the student's application that the counselor completes this section. Failure to do so will delay the process. Please be candid in your remarks.
Counselor FULL Name *
Counselor Email Address *
Counselor Remarks:
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