Newcomer Elementary - Kelley O'Neill 845-291-0200 ext. 10661

Newcomer GED and Secondary Program- Barbara Gasperetti 845-291-0200 ext. 10260/845-469-3995

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STUDENT INFORMATION:

Referral Date

Requested Start Date*

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Last Name*

First Name*

DOB*

Dominant Language

Other Language

Home School District*

District Contact Person

District Contact Email

District Contact Phone #

Hispanic*

Yes

Race*

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Black or African American

White

Two or more races

Recommended Program:*

Newcomer Elementary (K-5)

Newcomer Secondary (6-12)

Newcomer GED (16+)

FAMILY INFORMATION:

Parent/Guardian Name*

Home Phone Number

Mother Work Number

Father Work Number

Street Address*

City*

State*

Zip Code*

Emergency Contact *

Emergency Phone Number*

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NYS Identification Test for English Language Learners (NYSITELL) Test Results*

Student with Interrupted Formal Education (SIFE)

Newcomer

Entering (Beginning)

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Authorization*

By checking this box and signing you are authorizing that you are the district contact person submitting this form

Please Type Full Name

Title

Date

Signature

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Please note: Be sure to attach all current evaluations, reports, etc. An Intake conference will not be scheduled or a placement decision made without complete reference materials on file.

The following records should be included with this Referral Form:

*Recent Social History

*Health and Immunization Records

* Academic Achievement Data (NYSITELL results, transcripts - local &/or previous)

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