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Auglaize County Alternative School Intake Form 2021-2022
Date for Assignment must be confirmed by the Alternative School monitor in advance.
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* Indicates required question
Option 1
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Reason:
Your answer
*
Your answer
Fax Number or Email for Exit Report:
*
Your answer
*
Your answer
Grade Level
*
Your answer
Number of Days
*
Your answer
Start Date
*
MM
/
DD
/
YYYY
IEP Student?
Yes
No
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If yes, please list any special directions.
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Will student need access to a computer?
*
Yes
No
If yes, for what assignments?
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Reminder Checklist:
Students will not be allowed to bring a jump drive from home.
Student has been told bus transportation times.
Student has been told to pack lunch or bring $2.80 for full or $.40 for reduced lunch from Wapakoneta Middl School
Student has been told no electronic devices, including cell phones and iPods, will be allowed.
Emergency Meidla form has been faxed or sent with student.
Assignment sheet has been faxed, emailed, or sent with student. (email
lsteinke@auglaizeesc.org
)
Student has been told to bring all needed materials.
Student Lunch Status
*
Full Price
Reduced (Must provide free and reduce lunch form.)
Free (Must provide free and reduce lunch form.)
School Official filling out form:
*
Your answer
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