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Get Golden Valley Charter School Student Study Team Referral Form

: 619-562-7329 School: Date:_________ Person Completing Form (circle one): Parent Guardian ES Other: _______________ ES #: Student # : ES Name: Student name: Date of Birth: ________________ Age: _________ Grade: _________ Sex: M / F Parent #: Parents Name: Parents Address: Parents Phone: Email: Purpose Of Referral (Check all that apply) ___ Curriculum help ___ Health issues ___ Learning difficulties ___ Social/emotional problems ___ Appropriateness of school placement Other: ___________.

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