Student Enrollment Form - Acacia Academy

Student Referral Form

Please complete the application below. The Acacia Academy administration team 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.

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

Burr Ridge Campus

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

708.579.9040

Student Referral Form

My Infomation

School District Info

Student Info

Parent/Guardian Info

Acacia Academy Accredited Special Education School

Programs

About

Contact/Events