Education Reconnection High School Diploma Program Agreement

Counselors: You will need a copy of student IEP or 504 if applicable, copy of student transcripts, and copy of student credit analysis/audit

School

School District

School

Student Information

Please enter the student's full school email address and pick a match from the results. If nothing shows up or you only see a loading icon, tick the box to enter their information manually. If you see multiple duplicate options, please select the first one.

Student School Email Address

I don't see their email address

Student School Email Address

Student First Name

Student Last Name

Student Date of Birth

Grade Level

UIC Number

Credits Earned

Parent Information

Please enter the parent/guardian's full email address and pick a match from the results. If nothing shows up or you only see a loading icon, tick the box to enter their information manually. If you see multiple duplicate options, please select the first one.

A copy of this form will be sent to them via email for them to sign off on.

Parent/Guardian Email

I don't see my email address

Parent/Guardian Email

Parent/Guardian First Name

Parent/Guardian Last Name

Is the student eligible for free/reduced lunch?

YesNo

Does the student have an IEP or 504 Plan?

YesNo

Please select which apply.

IEP504 Plan

Please upload the student's IEP.

Please upload the student's 504 Plan.

(If yes, please attach the most recent document)

Reason the youth is being recommended for the program

***Please include a copy of the most recent transcript and credit analysis

Transcript

Credit Analysis

Counselor Name

Counselor Email Address

Please enter your principal's email address. A copy of this form will be sent to them via email for them to sign off on.

Principal Name

Principal Email Address

School District ID

School ID

Student Contact ID

Parent Contact ID

Please Sign Your Name Below

This electronic/digital signature is the same as a handwritten signature for the purpose of validity and legality

Contact Information