GCESC Project LIFE Teacher Referral Form

GCESC Project LIFE Teacher Referral Form

Referrals for the 25/26 school year will be accepted from Dec. 1- Jan. 31. Interviews take place after the referral is received in Feb/ Mar. ***This form is for school staff to fill out on the student who is applying.****
Student's Name*

First NameLast Name
School*
Referral Person's Name*

First NameLast Name
Referral Person's Title*
Referral Person's Phone Number*
Please enter a valid phone number.
Referral Person's Email*
example@example.com
Name of Primary Parent to Contact*

First NameLast Name
Parent's Phone Number*
Please enter a valid phone number.
Parent's Email
example@example.com
Does the student have any unexcused attendance issues?*

YesNo
What is the students grade equivalent in Reading? blanks*
& Math?blank*
Has the student participated in some form of training for employability at the school? If so, please list training site(s) and rate current work level below:*
Please rate current work level here:

5 or more prompts (requires a lot of direction, task modification)Improving, 3-4 prompts (basic skills, some competence)Meets expectations, 1-2 prompts (able to perform tasks with limited instruction)Independent, no prompts (competitive level)
Does the student require the help of a one on one aid in the classroom?*
Please explain any accommodations needed by the student in the classroom or at job training site(s).*
Does the student have a concept of work and a desire to perform work tasks?*

YesNoSometimes yes, sometimes no
Please explain if needed.
Does the student have enough stamina and/or physical ability to perform job tasks for at least 2 hours at a time?*

YesNo
If no, please explain.
Is he/she able to focus in on a task (after initial training) with limited prompting from others?*

YesNo
If no, please explain.
Is the student able to complete basic self care without assistance?*

YesNo
If no, please explain.
He or she can exhibit appropriate social skills in a work setting and does not have major behavior issues.*

YesNo
If no, please explain.
Student is able to take direction and constructive criticism from a supervisor without being disrespectful or displaying inappropriate behaviors.*

YesNo
If no, please explain.
Student is able to identify safe and unsafe situations independently or with minimal prompts.*

YesNo
If no, please explain.
If the student has mobility concerns and/or uses communication devices he or she is willing and able to use any adaptive equipment with minimal assistance.*

YesNoN/A
If no, please explain.
Is there any other information that we should know about the student that you are referring?
Important Information:

Please e-mail a copy of the student's IEP and ETR to: kbrown@greeneesc.org. (Parents/students gave permission to share these records as part of the application that they filled out.)
Should be Empty: