MRVED - Minnesota Valley Area Learning Center TARGETED SERVICES REFERRAL FORM Keep in c !

"ol#er "or $ years

Use this form to initiate the process of referring a student to a Targeted Services -- specialized summer or after school program. Classroom teachers must complete sections 1-5. The office will complete section 6 and return the form to the building principal. Section 1 STUDENT !E#E!!$NG TE"%&E!'TE"( Section * (raduation "ncentives +(", Criteria !ersonal "nformation (Note: Grade level should be current year or, "# SU$$%& !&'(&)$, grade level that the student will enter in the fall) GENDE! D"TE G!"DE

The Graduation $ncentives (G$) criteria and other at)ris* indicators +ust be considered for the referral, Students +ust -ualify in at least one of the areas listed in this section to be eligible for this .rogra+, %hec* (/) all that a..ly, "tems 1- *- and 11- need at least one specific academic +Section ., or social personal /ualifier +Section 0,. 0, 2, 3, 4, 5, 7, 8, 9, :, 0;, 00, Section . 1erfor+s substantially below average on a local achieve+ent test, $s at least one year behind in co+.leting coursewor* satisfactorily, $s .regnant or a .arent, &as been assessed as che+ically de.endent, &as been .hysically or se6ually abused, &as e6.erienced +ental health .roble+s, &as e6.erienced ho+elessness in the last si6 +onths, S.ea*s English as a second language or has li+ited English .roficiency, &as been e6cluded or e6.elled according to sections 020",4; to 020",57, $s chronically truant or has withdrawn fro+ school, &as been referred by a school district for enroll+ent in an eligible .rogra+ or a .rogra+ .ursuant to section 024D,7:, )cademic1)chievement Test 2ualifiers +Complete onl3 if 41- 4*- and or 411 is selected in Section *, ("T& !E"D$NG =!$T$NG

TEST T<1E N=E" $T>S ST"! %"T

TEST T<1E

("T&

!E"D$NG

=!$T$NG

(%" Ather:

Section 0 Social 1!ersonal 2ualifiers 5555?ow +otivation "cade+ic failure in current classes #ailure to co+.lete assigned wor* Does not de+onstrate study s*ills #ailure of teacher ad+inistered tests Difficulty in classes of large si@e E6cessive absenteeis+ $solation fro+ .eers E6cessive off tas* behaviors Socially ina..ro.riate co++ents 1oor organi@ational s*ills ?ow self)estee+'self)conce.t

Section 5

"dentified S6ill 7evelopment )reas (0) (ost $+.ortant (2) ?ess $+.ortant (3) ?east $+.ortant
=riting S*ills (ath S*ills Study' Argani@ational S*ills Social'1ersonal S*ill

!eading S*ills

223830880.doc Updated 4/21/2014 Page 1