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Check and Connect Referral
The Pinon Project Check and Connect Student Advocacy Program
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MM
/
DD
/
YYYY
Student Name
Your answer
What district does your child attend?
RE-1 (Cortez)
Dolores District
Clear selection
School and Grade Level
Your answer
Referrer's Name
Your answer
Referrer's Email
Your answer
Referrer's Phone Number
Your answer
Parent Name
Your answer
Parent Phone Number
Your answer
Parent Email
Your answer
Home Address
Your answer
List known siblings or other children within the home
Your answer
Check all that Apply
Poor Attendance
Disruptive Behavior
Incomplete Assignments
Poor Performance
Tardy
Disengagement
Other:
Average Grade
A
B
C
D
F
Parents Involvement in Child's Education
High
Adequate
Low
Clear selection
Is the student recieving any additional services?
IEP
504
Tier Supports
List any other supports/interventions (academic or social) not listed above.
Your answer
Please add information based on your experience with the student and family.
Your answer
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