Lori Costello,
Regional Superintendent

Staci Oliver,
Assistant Superintendent

STUDENT NAME *

First

Last

SIS NUMBER *

GRADE *

F-L *

IEP *

DISTRICT NUMBER *

SCHOOL *

SCHOOL CONTACT NAME *

SCHOOL PHONE CONTACT NUMBER *

SCHOOL CONTACT EMAIL *

Confirm Email

PARENT CONTACT NAME *

PARENT PHONE CONTACT NUMBER *

REASON FOR REFERRAL *

DATE'S OF SUSPENSION *

Please Select all days of suspension

STUDENT ASSIGNMENTS *

MODE OF STUDENT TRANSPORTATION *

UNERLYING MEDICAL ISSUES OR ALLERGIES. *

Additional Information

8 A.M. – 4:30 P.M. Monday-Friday
Phone: (618) 825-3900

8 A.M. – 4:30 P.M. Monday-Friday
Phone: (618) 825-3900