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Name *

First Name

Last Name

Student Date of Birth *

MM

DD

YYYY

Parent or Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

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.