The Westbrook/Windham
21 Century Community Learning Center (CCLC)
st
~To provide quality after-school and summer programming that addresses and nurtures the social, emotional,
and academic needs of students facing hardships in their school community.
Restorative Learning Program-Teen Aspirations Program-LAS Tutoring-Summer School-Parent Programming-Adventure Based Activities
21st Century Community Learning Center
Intake Referral Form
Please check the program you are referring the student to:
Restorative Learning Program Summer Adventure Academy_________
Student Name: Referral Date:
School: Grade:
Gender: Age Birth Date:
Phone: Address:
Parent/Guardian Name:
Parent Permission for Referral: YES NO By: Phone In-person Other
Parent/Guardian Phone:
MaineCare/ Insurance #______________________________________________________________________________
Emergency Contact:
Living Situation (i.e. lives at home, foster care, group home, homeless, etc)
Allergies/Medical info:
Other Service Providers or Caseworkers:
Person Referring: Explanation for Referral
For summer school:
Please indicate whether the student needs to earn credit in Math________ or English_______ or .5 in both
Brief Student Profile (Please check all that apply):
____Truancy ____Alternative Learning Style _____Special Education Needs _____Discipline Issues
____Credit Deficiency _____Juvenile Justice Involvement ____Disaffected/Lacks connection with current Placement
Please attach: Academic Transcripts Disciplinary Records Lexile Score _____NWEA
Ethnicity (please circle):
American Indian or Alaskan Native African American Asian or Pacific Islander Caucasian Hispanic
Does the student qualify for free or reduced lunch? YES NO
21st Century Community Learning Center*Serving Westbrook/Windham School Districts*Located in the REAL School, Windham
Mail: 55 High Street, Windham, ME 04062
Phone:892-4462*Email: sanderson@windham.k12.me.us
Funded by the Maine Department of Education