Cattaraugus Allegany BOCES
Cattaraugus Allegany BOCES
ALTERNATIVE EDUCATION APPLICATION
Student information
Social Security #:
Student’s name: DOB:
Address: District of Residence:
_______________________________________________
Parent/Guardian: Phone:
Emergency Contact Name: Relationship:
Address/phone # (if different): Contact phone:
Outside Agencies or Affiliates (DSS, Probation or other)
Agency: Contact:
Agency: Contact:
Please check “Yes” or “No”
Yes No Other Barriers to Academic Achievement Yes No Economically Disadvantaged
Yes No Disabled (IEP) Yes No English Language Learner
Eligibility Criteria
(Please check all that apply)
Low Academic Achievement Excess Absences Discipline Level 2/3
CSE Placement Violated Attendance Policy Excessive Referrals
Grade Repeater At Risk for Dropping out Excessive ISS Days
Poor Regents Performance Placed on PINS Excessive OSS Days
Level 1 or 2 (8th Grade Assessments)
Program Choices
(Please check age appropriate program and location)
Regents Diploma Local Diploma GED Diploma IEP Diploma
CTE Undetermined
*Please attach NYS Form B if GED student
**Completed Application should come from the guidance office or CSE with a copy of all pertinent records**
District Authorized Signature:
TO BE COMPLETED BY BOCES ADMINISTRATION AT INTAKE :
Interview Date & Time: Enrollment Date:
Change of Program (From/To): Date: ______________
Grade:_____________ Advisor: _________________
Student’s Signature: Date: ________
Parent/Guardian’s Signature: Date: ________
Principal’s Signature: Date: ________
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