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All referrals of students to the program must be made by a member district. Parent and agency inquiries will be redirected to the home school district. Any administrator may make a referral of a student to the program by contacting Evergreen Academy and requesting the appropriate referral materials or by printing out the referral packet below.  A student interview will be scheduled upon receipt of a completed packet and all requested information found on the Referral Profile checklist.  

The purpose of the referral process is to gather information on the student's needs and eligibility for the Regional Safe Schools Program.  Below are the steps necessary to complete the process.

  1. Contact Evergreen Academy and request a referral packet. Or print one below.

  2. Complete and return via email or fax ALL required paperwork.

  3. Referral packet will be reviewed to determine student eligibility

  4. Referring school liaison will be contacted to arrange an interview/intake meeting with perspective student, parents and school district representative. 

Required Paperwork:

  • Disclosure of Records

  • Student Data Sheet - including SIS

  • Referral Information

  • Disciplinary Files

  • Current Grades and Credit Status

  • Attendance History
  • Support Service and Intervention History
  • School Physical, Immunization and/or other health records
  • Student Interview (completed by student)
  • Youth Information Form-Parent Interview (completed by parent)

Evergreen Academy Referral Packet

Also available under the FORMS tab.

Send completed paperwork to:  or  Fax to: 815-923-4450

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