SRCSC Alternative Program
STUDENT INFORMATION (ALL INFORMATION IS CONFIDENTIAL)
FILL OUT THIS FORM COMPLETELY AND SUBMIT TO GUIDANCE BY_________________.
Date of Birth___________________
Street Address_______________________________________ City____________________
Student Home Phone (______)_____________
Student Cell Phone (______)_____________
Student E-mail Address__________________________________________________
Live with _______________________________________
Parent Home Phone (______)_____________
Parent Cell Phone (______)_____________
Parent E-mail Address__________________________________________________
Referred by (School Administrator, Counselor, Parent, Student or Teacher)_____________________________________________
Reason(s) for referral:
Are you Pregnant? Yes_____ No_____ Due Date: _______
Have a child? Yes_____ No_____
Child Care Provider___________________
Provider’s Phone (______)_____________
Do you work? Yes_____ No_____ If yes, where?
Work Phone (_______)______________
Please check your answers.
1. I have repeated a grade: yes_____ no_____ when___________________
2. I enjoy reading:
not at all_____ some_____ very much_____
3. I have difficulty in school because of my reading ability:
a lot_____ some_____ not at all_____
4. Number of hours per week I usually study outside of school:
less than 3__________ 3-9_________10 or more_________
5. In my opinion my present study habits are:
poor_____ fair_____ good_____ excellent_____
6. I am doing as well in school grades as my parents expect me to do:
don’t know_____ yes_____ no_____
7. I am doing as well in school grades as I expect myself to do:
8. Graduating from high school is:
not important_____ important_____ very important_____
9. How much time outside of school do you spend with your friends?
10. What is your favorite class or subject in school?
11. What is your favorite hobby?
12. Why do you want to go the alternative school?
13. What problems have you had in school in the past? Check the items that apply to you, and explain each as best you can.
_____Attendance _____Conflict with others
_____ Behavior _____ ________________
14. How do you think the alternative school will help you solve these problems?
15. What are your plans after graduating from high school?
16. How do you want your name to read on your diploma?