Restorative Training Center Referral

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This is a referral form for the Restorative Training Center located at The Boys & Girls Club Paul I Phillips location at 726 Madison Ave SE, Grand Rapids, MI 49503. If you have any questions while completing this form please call Eddie Edwards at 313-449-6770. At this time we are unable to provide any transportation - if this changes we will be sure to let you know.

Email *

Student's Full Name *

Phone Number *

Home Address *

Student's Grade *

Student's Age *

School Attending *

Emergency Contact #1 Name *

Emergency Contact #1 Phone Number *

Emergency Contact #1 Relationship to Student *

Emergency Contact #2 Name *

Emergency Contact #2 Phone Number *

Emergency Contact #2 Relationship to Student *

Dates of Suspension *

Student's Areas for Development *

Academic Needs/Classwork Due *

Recommendations/Additional Information *

Suspension Report Provided by the School? *

Yes

Does the student want to stay after 2:30 to join the Boys & Girls Club? *

Yes

Parent/Guardian Typed Signature *

Date form was completed *

YYYY

Submit

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