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Early Alert Referral Form

The Early Alert Program is designed to identify those students that are at risk. This program is designed for early intervention of at risk behaviors. Below is a list of possible reasons one may choose to refer a student through the Early Alert Program:

  1. Class absence exceeds allowed limit.
  2. Significant changes in academic performance (i.e. failing quizzes and tests, not turning in assignments, etc.).
  3. Decrease in neatness of appearance.
  4. Changes in demeanor or behavior.
  5. Signs of withdrawal, depression, sadness, loneliness, homesickness or moodiness.
  6. Signs of disinterest or lack of motivation.
  7. Other
*Marked items are required information in order to successfully submit an Early Alert.
About the Student
1.*Name:
2. Address
3. Phone
Your Information
4.*Your Name:
5.*Your Phone:
6.Your Relationship to the student:
7. Please indicate the nature of the student’s problem which you believe jeopardizes his/her academic success and/or continued matriculation. Please use this space to clarify the problem.
8. Please give any background or additional information that you have on the student.
8a. *Have you contacted the student about these issues presented
Yes
No
8b. If Yes, Please describe.
9. Do you want the student to know who made the referral?
Yes
No
Does Not Matter