2024-2025 - DULUTH AREA LEARNING CENTER REFERRAL FORM

2024-2025 - DULUTH ALC Seat-Based REFERRAL FORM and CONTINUAL LEARNING PLAN

Technology Village Suite 450, 11 E Superior St, Duluth, MN 55802 PHONE: (218) 336-8756 FAX: (218)336-8770
The ALC Seat Based Program is open to youths ages 15-20 who meet one or more of the state eligibility guidelines.

Seat Based Learning requires class attendance Monday-Thursday from 8:00am-11:40am. Students may also earn elective credit(s) via successful participation i nwork experience.

PARENTS/GUARDIANS: Please be sure to completely fill in the referral form, sign, and submit. We cannot enroll your student without your signature.
Student Information:

Parent/Guardian, please fill out
Name

First NameMiddle InitialLast Name
Gender

MaleFemale
Birthdate

MonthDayYear
Date
Student Personal Email
Student Cell Phone
Student Grade
Graduation Year (GSY)
MARSS #
FOR NON ISD709 STUDENTS
Last School(s) Attended
Parent/Guardian Name 1
Parent/Guardian Name 2
Parent/Guardian Email 1
example@example.com
Parent/Guardian Email 2
example@example.com
Parent/Guardian Phone 1
Parent/Guardian Phone 2
Primary Address
House # and Street Name (APT # if applicable)
City
State
Abbreviation
Zip Code
Students not currently enrolled in ISD709 should provide an updated transcript and a copy of the most recent report card. (For seniors, clearly indicate the class(es)/ credit(s), elective and/or required, that need to be completed before a diploma will be issued.)
** REQUIRED ** ALC students must meet MN state requirements for enrollment. Please select ALL that apply*

Performs substantially below the performance level for pupils of the same age in locally determined achievement testHas experienced mental health problemsHas experienced homelessness sometime within six months before requesting a transfer to an eligible programSpeaks English as a second language or has limited English proficiency (LEP)Has been excluded or expelled according to sections 121A.40 to 121A.56Has been referred by a school district for enrollment in an eligible program or program pursuant to section 124D.69Is a victim of physical or sexual abuseIs at least one year behind in satisfactorily completing coursework or obtaining credits for graduationIs pregnant or is a parentHas been assessed as chemically dependentHas withdrawn from school or has been chronically truant
Does Student Have a 504 Plan?

YesNo
Has student received Special Education Services (IEP)?

YesNo
If student has a 504/IEP plan, please submit a copy to ALC by any of the following options:
- Email
  - kathleen.wilson@isd709.org
  - valarie.wagenbach@isd709.org
- Fax
  - 218.336.8770
- Stop into ALC
  - Monday-Thursday
  - 8:00am-5:00pm
If student has a 504/IEP plan: Prior to an ALC referral, the ALC Special Education staff and administration will be notified of a possible referral and will be part of the referral process. They will attend a record review meeting (meetings held 8:00-8:45am at student's home school.) The meeting will review the most recent assessment and current/past IEP's and interventions utilized. Please contact Nathan Glockle at 218.336.8700 ext. 2141.
Case Manager Signature

Clear
Date

MonthDayYear
Case Manager Email
Current Services

Student qualifies for Families in Transition
I (student) understand the ALC program requirements. I will work cooperatively with my counselor to develop a Continual Learning Plan (CLP) and promise to put forth full effort to achieve my stated goals. (See CLP form continued below signatures.)
Student Signature

Clear
Date

MonthDayYear
Date
I (parent/guardian) understand the ALC program requirements. I support the decision of my son/daughter to enroll in the program and expect him/her to work cooperatively with his/her counselor to develop a Continual Learning Plan (CLP) and to put forth full effort to achieve the stated goals. (See CLP form continued below signatures)
Parent/Guardian Signature (required for students under 18)

Clear
Date

MonthDayYear
Date
Section 3

STAFF ONLY
** REQUIRED ** Educational goals for the current school year *
Courses student is enrolling in
Counselor/Admin Signature

Clear
Should be Empty:

2024-2025 - DULUTH ALC Seat-Based REFERRAL FORM and CONTINUAL LEARNING PLAN

Student Information:

Section 3