PLEASE UTILIZE THE FOLLOWING LINK https://ju4y.herokuapp.com/referral/

Student Name (Full Name) (In the order of first, middle, and last name) *

Date of Birth *

MM

/

DD

/

YYYY

Sex *

Female

Male

Date Referred *

MM

/

DD

/

YYYY

Grade Level *

School Name *

(Type in the box 'other' if you want something different)

Allison Elementary School

Armstrong Elementary School

Barfield Elementary School

Diamond Point Elementary School

Emerson Middle School

Fremont Academy of Engineering and Design

Ganesha High School

Garey High School

Golden Springs Elementary School

Harrison Elementary School

ICOE

Kellogg Polytechnic Elementary School

Kingsley Elementary School

La Verne Science And Technology Charter School

La Verne Charter

Lexington Elementary School

Lincoln Elementary School

Lopez Elementary School

Lorbeer Middle School

Madison Elementary School

Montvue Elementary School

No School

Palomares Academy Of Health Sciences

Pantera Elementary School

Park West High School

Pomona High School

Ranch Hills Elementary School

Roosevelt Elementary School

San Antonio Elementary School

Vejar Elementary School

Village Academy High School

Westmont Elementary School

Other:

Student's GPA:

JU4Y Programs

On-Point
- A restorative program that focuses on serving students social-emotional needs, the development of healthy relationships, character & leadership skills.
- Focused around tier 1 & 2 students and at promise students.

Connect
- Program focused on mentor matching and mentor events.
- This program creates a safe space to build relationships with teens.
- Weekly mentor events.
- Off-campus community based program.

T.R.E.E
- A support program for parents
- Restorative program that focused on training, resources, empowering and educating parents

RES’Q
- Reconnecting and engaging students quickly
- Focused on increasing graduation rates, preventing drop-outs and retaining enrollment
- This program includes outreach, enrollment, and mentoring services

KEEP
- Providing quality tutoring services to youth
- Focused on knowledge, education, empowerment, and possibilities

PAC’D
- Assists teens to reconcile with their families, community, and themselves through
- Parent & Individual Counseling
- Anger Management
- Community Service
- Drugs & Alcohol

Restorative Justice & Care
- Offers community education & expanded participation in restorative justice and its practice
- Conducts & joins regular listening circles to build healing relationships, raise the voice of at-promise youth, & promote dialogue
- Centers youth diversion efforts on community relationships to improve alternative sentencing
- Provides mentoring & educational opportunities with system-impacted youth in, or affected by, foster care, group homes, jail, and/or prison

TAY Housing
- This program provides emergency housing and relief to former foster youth and TAY aged youth (18-21)

YES Program
- A vocational program focusing on vocational training and opportunities

Program Referred To: *

Connect Program

KEEP Program

On Point Program

PacD Program

ResQ Program

RJ+Care Program

TAY Housing Program

TREE Program

YES Program

Required

(Please answer If the student was referred to KEEP Program) Subjects to focus on (check all that apply)

(Type in the box 'other' if you want something different)

English - Reading

English - Writing

English - Grammar

Math

Other:

Reason for Referral *

You can mark up to 3 categories (Type in the box 'other' if you want something different)

Lack of student engagement

Emotional/physical wellness

Drugs/alcohol addiction

Violent disruptive behavior

Needs mentoring/continuing

Other:

Required

Details of the reason

Referral made by (type name): *

Relation to Student who was referred *

(Please type in the box 'Other', if you want something different)

Mentor

Principal

Teacher

Tutor

Counselor

Other:

Race/Ethnic background

-American Indian/Alaska Native (not Hispanic or Latino)
Persons having origins in any of the original peoples of North and South America, (including Central America), and who maintain tribal affiliation or community recognition
-Asian (not Hispanic or Latino)
Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam
-Black/African American (not Hispanic or Latino)
Persons having origins in any of the Black racial groups of Africa
-Hispanic/Latino
Persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race
-Two or more Races (not Hispanic or Latino)
Non-Hispanic persons who identify with more than one of the following five races: (1) White, (2) Black, (3) Asian, (4) Native Hawaiian/Other Pacific Islander, (5) American Indian/Alaska Native
-Native Hawaiian/Other Pacific Islander (not Hispanic or Latino)
Persons having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands
-White (not Hispanic or Latino)
Persons having origins in any of the original peoples of Europe, the Middle East or North Africa

RACE/Ethnic background (CHOOSE ALL THAT APPLY) *

Asian/Asian Americans (not Hispanic or Latino)

Black/African American/African (not Hispanic or Latino)

Hispanic/Latino/Latina/Latin

Native American/American Indian/Indigenous/Alaska Native (not Hispanic or Latino)

Pacific Islanders/Native Hawaiian (not Hispanic or Latino)

White/Caucasian/European Multi-Racial (not Hispanic or Latino)

Two or more Races (not Hispanic or Latino)

I Choose not to disclose

Required

Does student have a learning disability? *

Yes

No

I don't know

If you answered 'Yes' to the question "Does student have a learning disability?", what kind of learning disability?

Student Email or School Email Address

School ID Number

Phone Number

Address *

Address, City, State, ZIP

Primary Language (Language spoken at Home)

If 'Other', please type in the box "Other"

English

Spanish

Other:

Clear selection

English Proficiency *

Basic

Conversational

Fluent

Proficient

Continuing with JU4Y? *

Yes

No

I don't know

Student's Counselor Name (first name then last name)

Parent/Guardian Name: (In the order of first name then last name) *

Relation to Student: *

Parent/Guardian Phone number:

Parent/Guardian Email:

Academic Tier

Tier 1

Tier 2

Tier 3

Clear selection

(Please answer If the student was referred to KEEP Program) Student's Lexical Score

(Please answer If the student was referred to KEEP Program) Student's iReady Score

Other Assessment Info

Other pertinent details: