East Bay Career Academy

School District and Educational Information

Student’s name                                                                                                            

Reason for referral.  Please attach additional pages as needed                                         

The following evaluations/reports completed within the past 3 years are attached. Check those included.

Name and phone number of person in the district responsible for managing this referral procedure. 

               Name                                                                               Phone

Name and phone number of person in the district designated to be primary contact to deal with questions and issues as they may come up during the course of the initial trial Admission, or after a permanent admission. 

               Name                                                                               Phone

If the student has an IEP, name and phone number of person in the district who will be responsible for attending and assisting at all IEP related meetings, including those that may be held during the initial 20-day probationary admission phase.

               Name                                                                               Phone

Adaptive Equipment Used: (wheel chair, magnifying glass)                                               

Support services currently receiving                                                                                

Current work history and available transportation