EmailMe Form - FOUR OAKS FACESHEET 2014-2015 Page | of 4 FOUR OAKS FACESHEET 2014-2015 Please fill out the fields below and click "submit" by 2:30 pm the day before the student is scheduled to begin at Four Oaks in the suspension/intervention center. Please remember: - IF THIS FACESHEET IS SUBMITTED AFTER 2:30 PM, we will not be able to acccommodate the student tomorrow/the next school day. However, we still may be able to the following day, depending on space available, For instance, if itis 3:02 pm on Tuesday, the earliest we will be able to accommodate him/her would be Thursday. - IF THIS FACESHEET IS SUBMITTED BEFORE 2:30 PM, we look forward to seeing the student our next school day! Toconfirm, this will be sent back to you via email by Four Oaks staff. Thank you! Student Name:* School:* Dac C Hempstead HS. Jefferson Ms Roosevelt MS CO Senior HS C1 Washington MS “ALC Staff: Please mark ALC + the hame/sending school School Contact Person:* (This should be the administrator or SpEd Coordinator assigned to and/or sending the student) School Contact Person Email:* Other School Contact(s) Emails: [@ Please list the emails of any additional home school personnel that this facesheet shouldbe forwarded on to besides the school contact person listed above. Type of Visit:* 1 Suspension (General Education) C1 Suspension (Special Education) C1 intervention (Special Education). Grade:* 06 O7 bttp:/www emailmeform.com/builder/form/y7Kh4180FBV0003 3n2n015[EmailMe Form - FOUR OAKS FACESHEET 2014-2015, Page 3 of 4 Does this student have any known [-] None known/recorded. ‘mental health diagnosis? Ifso, please list." Medication? * Insurance: Student Addres Hows this student being transported to Four Oaks in the AM?" Hows this student leaving Four (Oaks/getting home in the PM?" Emergency Contact #1:* Phone* Emergency Contact #2: Phone Parent Email Address: O Yes (please list): ‘© None known. ‘© Yes, but not taken at school. © Yes, at school. Please list med information: List any other relevant health information in last box. D Tite 19. Ti Unkown. DB other: © Bus home schoo! must make arrangements). ‘O Home school personnel will transport. © Walking. ‘© Other. Please explain: Ifthe student is taking the bus (either or both ways), the home schoo! ‘needs to make arrangements, Four Oaks will not be calling transportation O Walking, ‘© Bus (home school must make arrangements). © Home schoo! will transport. © Other. Please explain: If the students taking the bus (either or both ways), the home school needs to make arrangements, Four Oaks willnot be calling transportation. J First iast Please be sure this s the parent/legal guard 1-5 wih First Last tae ae aR {iflenown) bspy/tvwov-omailmeform.com/builder/formly7Kh4180FBV0003 30122015EmailMe Form - FOUR OAKS FACESHEET 2014-2015 Page 4 of 4 ‘Work & Consequences? * Completed Work: Additional Information: © Home school personnel will drop off. © Work will be emailed/scanned in and sent to Tyler (tszymanski@fouroaks.org). (© student wil bring with hem, O other: Send back with student after his/her stay in suspension. © Suspension Center staff will email to school contact person, ‘© Suspension Center staff will send back through district mail, O Other: C1 substance - includes (but is not limited to) possession, smoking, selling, using. C1 Violence - includes (but is not limited to) fighting, physical assaults, threats, harassment, weapons, 1 Defiance - includes (but is not limited to) failure to serve detentions, insubordination, disruption. C1 Attendance - includes (but is not limited to) truancy, tardiness. 1 Multiple referrals (please indicate reason(s} in Other" orin “Additional Information” box below) Ci Consequence as outlined in IEP/BIP. CO Other: A v ‘This might be health information fallergies), a copy-and-paste of his/her referral, etc. This could also be notes specific to the home school for YOUR documentation (for example, “A. Smith spoke with ‘Sam's mom -not dad - for permission") Powered by ‘SY EMF Contact Form Report Abe |itp:/wwww.emailmeform.com/builder/form/y7Kh4180FBV0003 3nza015