New Student Information/Referral Sheet:

Springbank Community High School - Learning Support Program

Date Completed: ____________________ Referring Teacher/Parent/Admin/Counselor: _____________________________

Student (Legal & Common) Name: _____________________________________________________________________________

Entering School Year: ______________ Current Grade: ______ Former School: __________________________________

Parents/Guardians: ___________________________________________________ Contact #: ______________________________

Attendance: Extremely Poor____ Sporadic ____ Good ____ Excellent ____ Comments: ______________________________

Last Year Core Subject Marks: Math _________ LA _________ Science _________ Social _________

Learning Strength: Visual ____ Auditory/Verbal____ Hands-on ____ Concrete ____ Other: _________________________

Formal Assessments: Name of Assessment Tool or Report: __________________________________________________________

Date Completed: _____________ Alberta Education Code: _________________________________________________________

Report Summary/Recommendations: ____________________________________________________________________________

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Inclusive Ed. Background/Support Services Involved: ________________________________________________________________

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Extra-curricular/Interests/Strengths: ____________________________________________________________________________

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Academic Needs: _____________________________________________________________________________________________

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Previous Accommodations: ____________________________________________________________________________

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Medical/Physical Concerns: _____________________________________________________________________________________

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Behavioral/Social/Emotional Concerns:_____________________________________________________________________________

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Other: _____________________________________________________________________________________________________

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*Please attach copies of any current Diagnostic Assessments (WJIII), Formal Assessments, IPP’s, Behavior Plans, any Student
Action Plans and signed Learning Support Consent Form