Student Referral Form

Please complete the form below. The Acacia Academy administration will review the current Individualized Educational Program (IEP), 504 Plan, medical records and/or all relevant information to determine if Acacia Academy has a program to meet the needs of the student. Once submitted, an administrator will contact you. Should you have additional questions, please contact Noel Fouks at 708.639.4194 or email info@acaciaacademy.com.

My Infomation

Name of Person Completing this Form *

First

Last

Relationship to Student

School District Info

School District Name *

District representative Name *

First

Last

District Representative Email *

District Representative Phone *

Student Info

Student First Name / Last Name *

First

Last

Student Grade *

Student Date of Birth *

Parent/Guardian Info

Parent/Guardian First Name / Last Name *

First

Last

Parent/Guardian Contact Phone Number *

Parent/Guardian Contact Email *

Parent/Guardian Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Please Provide Additional Information About Your Student Here

IEP/504 Plan Documents *

Click or drag files to this area to upload. You can upload up to 3 files.

Please provide documents in PDF or Microsoft Word formats.

Optionally, Please Provide Eligibility, Transcript, or any Evaluations

Click or drag files to this area to upload. You can upload up to 3 files.

Please provide documents in PDF or Microsoft Word formats.

La Grange Campus
(Elementary & High School)

Burr Ridge Campus
(Transition Program Ages 17-22)

Mon - Fri: 8:00 a.m. - 5:00 p.m.

Ph: 708.579.9040 / Fax: 708-491-0131