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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