2018-2019 Referral Form

Please download all 9 pages. Complete ALL information requested. Please print clearly. Most of the form can be filled out online but a few sections have to be filled in manually and all signatures need to be done manually.


  • Page 1-2 – Referral Form

  • Page 3 - Program Information

  • Page 4- Check List for Parent/Guardian

  • Page 5-6 – Consent for Participation and Release of Information​

  • ​Page 7 - Emergency Contact Form

  • Page 8  Telephone numbers for Middle and High School Attendance Offices

  • Page 9 – Location of Second Chance Program

Please request a form via e-mail if you are unable to download.  You may also contact your local school for a hard copy of the referral forms. All information requests are confidential.

For PDF forms, you will need a PDF reader. Please download and install Adobe Acrobat Reader or a compatible program to view these files. Download the most current Adobe Reader here In order to fill out a PDF with fillable form fields, save the form and open it up in a reader.


Formularios en español - Haga clic en el nombre del formulario para descargar.  

Para formularios en PDF, usted necesitará Adobe Acrobat para ver estos archivos. Haga clic acá

All referral forms should be sent to Xenia Castaneda at xeniacastaneda@apsva.us

For questions, please call 703-278-2176.

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All rights reserved 2007- 2019