Smart Living Services Start your Smart Living journey! Name * First Name Last Name Student's Age * Student Date of Birth * MM DD YYYY Student Home School District * Option 1 Option 2 Parent or Guardian Name * First Name Last Name Phone * (###) ### #### Email * Select Your School District * Option 1 Option 2 Please choose the days of the week your child would like to attend the program. * Monday Tuesday Please choose whether your child will attend full or half day. * Full day (9:00 am to 2:00 pm) Half day (10:00 am to 1:00 pm) Projected Start Date * MM DD YYYY Arc Human Services has permission to share this form with my child's home school district for the purpose of coordinating services. * Yes No Consent * By consenting on this form, I am giving Arc Human Services permission for this referral to be made to the Student Transition Program for the student named above. I understand that you may need to share the information from my referral with professionals in other organizations (such as the student's school district). I am allowing you to share the information in my referral. I understand that I will be giving my personal information to you (Arc Human Services), and you will keep it safe on a management information system and use it to help plan and support the identified student needs. Thank you!