The Academy at Illinois Central College



ROE 53 Regional Safe School110 Fandel Rd.Germantown Hills, IL 61548Email: jgrant@ Mrs. Julie Grant, MSWDirector Email: jgrant@Office (309) 383-3002DIRECTOR WILL CONTACT FAMILY TO SCHEDULE INTAKE WHEN COMPLETE PACKET IS RECEIVEDOffice phone has a voice mail system for before/after hour messagesROE 53 Regional Safe SchoolTo be completed by the counselor, dean, or principal:Home School: _______________________________Counselor______________________________Date: ______________ Counselor Phone: __________________ Counselor email: ________________Student Name: ________________________________ State ID Number: ______________________________Parent Name:___________________ Address:_________________________ Phone:__________________Date of Expulsion/ Suspension__________ Expulsion term:____________ Date of return:_____________Total credits needed for graduation from your school: _____________________Please note “yes” or “done”: Constitution test needed_______________ SAT needed___________Required courses this student still needs to graduate:Signature of appropriate school personnelName________________________________Title:_______________________ Date: ___________________DOCUMENTATION NEEDED: Send to: ROE 53 Alternative Education Programs110 Fandel Rd.Germantown Hills, IL 61548Administrative Transfer letter on school letterhead explaining the dates of the expulsion/ suspension and offense committed and length of placement at Safe SchoolCurrent GradesA high school transcript to date Attendance recordsDiscipline recordsHeath records, both physical and dental.Safe School application4 year graduation plan completed by counselorTo Be Completed by Student or Parent or Guardian –Date of application: ______________________________________First Name:___________________________Middle Name: _______________________Last Name: ___________________________________________________________________Student’s address: ______________________________________________________________City/State/Zip: _____________________________________________________County: __________________________________________________________Parent’s Phone: ______________________________ Student’s Mobile #: __________________Birthday: _______________________________________________Ethnic/Racial Classification: Asian or Pacific Islander Alaskan Native or American Indian Hispanic Black/African-American/Negro Non-Hispanic White Non-Hispanic Non-resident Alien OtherSex: Male FemaleHome school where records are: _________________________________________________Counselor’s name and school: ___________________________________________________ Emergency contact (other than parent/guardian): _________________________________Emergency phone number of person above: ______________________________________Doctor’s Name: ______________________________________________________________Doctor’s Phone: ______________________________________________________________With whom do you live: Parents Grandparents Father Mother Self Guardian Other:___________________FatherName: _________________________________________________________________________Street Address: ___________________________________________________________________City/State/Zip: ___________________________________________________________________Home Phone: _________________________Cellular: ____________________________________Employer: _______________________________________________________________________Work Phone:___________________ Ext. _________ E-Mail:______________________________MotherName: __________________________________________________________________________Street Address: ____________________________________________________________________City/State/Zip: ____________________________________________________________________Home Phone: _________________________Cellular: _____________________________________Employer: ________________________________________________________________________Work Phone:__________________ Ext. ______ E-Mail:____________________________________Guardian:First Name: _________________________ Last Name: ____________________________________Relationship to student: _____________________________________________________________Street Address: ____________________________________________________________________City/State/Zip: ____________________________________________________________________Home Phone: _________________________Cellular: _____________________________________Employer: _________________________________________________________________________Work Phone:___________________ Ext. _______ E-Mail:__________________________________General Information – To Be Completed by StudentThis form is to be completed by the prospective student in their own handwriting or the application will not be accepted.Please answer the following questions on the space provided.1. What has motivated you to enroll in this program? ______________________________________________________________________________________________________________________________________________________________________2. Reasons for leaving home high school?___________________________________________________________________________________________________________________________________3. Which are you hoping to earn? High School Diploma G.E.D. 4. How will you be successful in this program?_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5. If you could change any three rules or policies at your home high school, what would they be: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6. If you could change any three things about yourself, what would you change? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________7. What do you like to do in your spare time? _______________________________________________________________________________________________________________________________a. Sports you like: ____________________________________________________________________b. Games you like to play: _____________________________________________________________c. Kind of books you like to read: _______________________________________________________d. School activities: __________________________________________________________________ ................
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