Community Partnership Program

Date: * +

School District: *

School Name: *

STUDENT INFORMATION

Last Name: *

First Name: *

DOB: * +

Age: *

Gender: *

Race: *

Ethnicity: *

Current Grade: *

Street Address *

City *

Zip *

Youth Phone #

Youth Email *

Youth Preferred Contact Method:

Call

Text

Email

Special Education *

504

IEP

N/A

Does Student Need an Interpreter? *

Yes

No

Language Req *

Tribal Affiliation *

Yes

No

Unknown

Tribe Name *

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name (Last, First) *

Relationship to Youth *

Address *

City *

Zip Code *

Phone Type: *

Parent/Guardian Phone # *

Parent/Guardian Email Address

Parent/Guardian Preferred Contact Method:

Call

Text

Email

Mail

Does Parent/Guardian Need an Interpreter? *

Yes

No

Parent/Guardian Language *

Parent/Guardian Military Involvement *

Yes

No

Unknown

SCHOOL OFFICIAL INFORMATION

School Official Name *

School Official Title *

School Official Phone # *

Email Address *

REFERRAL INFORMATION

Select the Main Reason Youth is Being Referred to CPP.
(Please add an additional reason(s) to the 'Additional Information to Consider' section). *

Level *

Interventions Attempted at School *

0/290 characters

Additional Reason(s) and Information to Consider

0/290 characters

Attach Any Supporting Documents (Suspension Report, Attendance, Police Report, Etc.)

YOUTH PROGRAM INTRESTS

Select All Program the Youth is Interested In
(This is Not An Official Admission to These Programs) *

180 Mentoring	2nd Cycle	Arts Connect
Changing Rein-Hands on Horses	Changing Rein-Agility	Drug & Alcohol Evaluation
Elements	Evening Center	Exhale
FYCOES	Girls Project	Meeting with Payton
Metals	Mountaineers	OSH-Life Coaching
Outdoor Life	Tacoma Boat Builders	Youth Assistance Program
Meet with Layla	OSH BIAS & MEDIA	OSH Healthy Relationships
TBB After School