Copyright @ Second Chance. 

All rights reserved 2007- 2019

2017-2018 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.  You will receive a pdf file from

All information requests are confidential.

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

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