2008-2009 Registration Form

  

Asset-Based Intervention Programs for Substance Abuse and Tobacco Education

 

Student Name: __________________________ Grade: ______ Age: _____ School: _______

 

Please complete the following application in its entirety. Fax the application to (303)387-0119.

 

 

PARENT/GUARDIAN SECTION:

Parent/Guardian Name: ________________________________________________________________________________________

Address: _______________________________________ Home Phone: ____________________ E-mail: ______________________

City: _______________________ State: _____ Zip: _______ Phone at which you can be reached: _____________________

Please identify your child’s behavior(s) of concern: _________________________________________________________________

___________________________________________________________________________________________________________

 

SCHOOL ADMINISTRATOR SECTION (REQUIRED FOR ABI):

Administrator Name: ______________________________________________ Phone:

 

School: _____________________________________Student’s Counselor: __________________________________

Please check all of those that are relevant for this student:

Referred for disciplinary action?

*

Yes

*

No If no, for what reason is this individual being referred? ___________

_________________________________________________________________________________________________

Suspension reduced based on Asset-Based Intervention participation: Yes o

*

No

*

 

If yes, note length of original suspension. ______ How many days reduced? ______ Is this a deferred expulsion? Yes c

*

No

*

  

Please identify the student’s behavior(s) of concern: _____________________________________________________

_______________________________________________________________________________________________

  

 

Requested Class:

   

 

ABI SUBSTANCE ABUSE INTERVENTION CLASS-6 week session

 

*

 

7th-12th Grade

           

  

 

TOBACCO EDUCATION CLASS-5 week session6

                

*

 

7th-12th Grade

                                         

  

 

◄

ABI/Tobacco Cessation Applicants

:

The Student Development Office is offering on-going 5 or 6 week interventions for students

who need assistance with substance abuse or tobacco use.

Application to these interventions is made on a strictly voluntary basis

.

The DCSD Student Development Office has the ultimate authority to discontinue the student’s enrollment if the student’s behavior is

contrary to an acceptable learning environment. Parents are to remain on site (sometimes attending with their child) during the child’s

intervention class

, as instructors are not liable for the child should they become disruptive and are asked to leave. The parent must be

available to assume responsibility of their child.

 

A non-refundable $50.00 fee is required to attend Substance Abuse class. Substance Abuse attendees should make their check out to

Professional Counseling Services, Inc. Tobacco Education attendees pay a non-refundable $40.00 fee, and may write their check to

Douglas County Schools.

Payments are brought to the first class.

Payment options may be arranged, please speak with your instructor. The cost of each class

is underwritten by Title IV Safe and Drug Free Funds.

 

Agreement for ALL

classes:

We understand that there will be direct communication between instructors, the Student Development

Office, and Douglas County Schools regarding the educational, emotional and behavioral progress of each student. We have read all

the above, understand it as well as any and all accompanying information regarding this program.

 

 

___________________________________________ _______________________________________

Parent/Guardian Signature

                                       

Student Signature

  

 

___________________________________________ _______________________________________

Principal or Designee Signature

                                  

Date

 

Form may be faxed to the DCSD Student Development Office at

303-387-0119

after it has been completed and signed by administrator and parent.

Please contact the Student Development Office at 303-387-0095 for additional information.