CLC Referral Form When making a referral to the CLC you can attend under the following three statuses: As a ‘fee for service’ (FFS) student - This means that you remain enrolled in your school; however, your school will purchase the subjects you decide to study. You must be at least 15 years old. FLO 85% - This means that you remain enrolled in your home school; however you will be provided with an onsite case manager at the CLC, as part of your FLO enrolment, and you will have access to the entire CLC and NASC curriculum. You must be at least 16 years old. NASC student - This means that you transfer from your home school and enrol as a FLO student at Northern Adelaide Senior College. You will be provided with a case manager and access to the entire CLC and NASC curriculum. You must be at least 16.5 years old. For either a FFS or FLO 85% referral; the following referral form must be completed in full with associated attachments. Your FLO Leader at your school of enrolment must also sign as approval of this referral. Your referral will not progress unless the form is completed in its entirety. A further condition of enrolment is as follows – please ensure a nominated representative attends the initial enrolment interview (such as APP Case Manager, site SSO), who is briefed on the students’ circumstances and can constructively contribute to enrolment interview process. It is expected this advocate/person will support the discussion at time of enrolment. Please note if this form and associated attachments has not been completed an enrolment interview will not be scheduled. There will be no variance to this and homeschool FLO leaders will be notified. Only one file can be uploaded per prompt. Please ensure that files are below 2MB. Email of the person completing this form: Student Details Student's Name (First and Last Name) Date of Birth Student Contact Phone Number Parent/Caregiver (First and Last Name) Current School of Enrolment Case Manager Contact Details Case Manager Name (First & Last Name) Name of the students current Case Manager (if no current Case Manager place a school contact e.g. FLO coordinator) Case Manager Phone Number Case Manager Email Address (required) Case Management Organisation Name AnglicareBaptist CareBarkumaCentacareConnected SelfEmployment DirectionsEmployment OptionsInComPro Youth Cultural Services for Aboriginal PeopleMission AustraliaNational Job LinkRe-Engage Youth ServicesRelationships AustraliaSave the ChildrenSchool-basedShaping FuturesSYC HYPATalking RealitiesUCWPAWhite LionWorkskilYourtown Program Selections This section will allow you to indicate the Program(s) that you are interested in for Semester 1 2020. Please remember that this is a Referral, not an actual enrolment. Check the CLC website for information about these courses. In addition to the subjects below; students at the CLC are able to access and study the full curriculum offered at Northern Adelaide Senior College. Please review all subjects on offer through our NASC website as these will be discussed at time of enrolment. ENGAGE Subjects AGFACommunity Aerosol ArtCommunity Digital PhotographyEnglishFuture Focus Life SkillsMathMediaMusicSportIce FactorNASC Subject(s) Emergency Contact Please provide the emergency contact of the student expressing interest in enrolling at CLC. Emergency Contact (First and Last Name) Emergency Contact Phone Number Please identify if you (or any partner e.g. APP, providing FLO case management, contracted through an Annexure C or any other arrangement), or any other representative at school site, believe that there are, or may be, any safety issues that the CLC needs to be aware of. YesNo If yes, provide details Documents Needed Please identify and attach as copies, any and all assessments the home school site has as part of the students’ record management (e.g. literacy assessment, psychological assessment, behaviour assessment etc). If there are no assessments please choose no. I have documentsNo Please attach documents here: Please identify if the home school has pre-committed any funding/expenditure that they expect NASC/CLC to meet the cost of, for an 85% enrolment. YesNo Please identify any pre-committed expenditure. Please record (and attach evidence as required) of any known medical issues (including allergies) and their status and management of each student. Medical Documents: Please reference and attach copies, of any and all plans, either previously completed and enacted, or current for the student (e.g. risk assessment & plan, positive behaviour plan, any and all learning plans – negotiated education plan etc). I have documentsI confirm there are no reports or plans for this student Please attach copies here: Please reference and attach copies of any and all reports, this should include at minimum the home school enrolment form, associated with the student (e.g. specialist referrals and associated documentation, critical incident reports etc). Please reference, and attach copies, of the student LLN ACSF level. (NB If the student has not completed a BKSB assessment to determine their ACSF level, ensure this actioned prior to enrolment interview at the CLC, and provide ACSF level, and evidence, before or at time of enrolment (this will work to support effective decision making the CLC at time of enrolment, to ensure adequate curriculum enrolment for student, and underpin optimal success and experience of each student). Identify the intended purpose of the initial referral (e.g. to complete SACE, to complete ‘compulsory’ SACE subjects and VET qualification, to obtain VET qualification and post school employment pathway, engage literacy & numeracy and life skills etc) Please confirm the FLO leader at the home school has approved this referral and associated expenditure to the CLC (provide the name of the FLO leader) YesNo Name of FLO Leader Please leave this field empty.