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PASS Referral Parent/Guardian Form
Please complete this form for participation in the PASS program.
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* Indicates required question
Student First Name
*
Your answer
Student Last Name
*
Your answer
Student ID #
*
Your answer
School
*
CC Griffin Middle
Concord Middle
Harris Road Middle
JN Fries Middle
Mount Pleasant Middle
Northwest Cabarrus Middlee
Roberta Road Middle
Winkler Middle
Hickory Ridge Middle School
Central Cabarrus High
Concord High
Cox Mill High
Hickory Ridge High
JM Robinson High
Mount Pleasant High
Northwest Cabarrus High
Early College High
CCS Opportunity School
Performance Learning Center
West Cabarrus High
Cabarrus Virtual Academy
Grade
*
6th
7th
8th
9th
10th
11th
12th
Incident Resulting in PASS Referral
*
Drugs/THC Product
Nicotine
Alcohol
Sexually Related Offense
Parent/Guardian First Name
*
Your answer
Parent/Guardian Last Name
*
Your answer
Parent/Guardian Phone Number
*
Your answer
Parent/Guardian Phone Number #2
Your answer
Parent/Guardian Email
*
Your answer
Does your child have a specialized health plan with the school nurse?
*
Yes
No
If yes, please make sure your school nurse is aware that your child will be attending PASS so that we can coordinate care.
I have notified my students school nurse.
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