ALTERNATIVE TO HOMEBOUND PROGRAM APPLICATION 
Send completed application to Liverpool District Office for review c/o Steven Garraffo, Room 4, 195 Blackberry Road, Liverpool, NY 13090 Phone: (315) 622-7155 Fax: (315) 622-7115 
PLEASE COMPLETE ALL INFORMATION 
Name _________________________________________________________________________ Student SIS Number _________________________ Date of Birth ________________________ 
Grade Level _______ 
Mother’s Name ______________________________________________________________ 
Father’s Name __________________________________________________________________ Student’s complete mailing address _________________________________________________ 
Parent’s Phone Numbers — Home________________________ Cell ______________________ Student Lives with _______________________________________________________________ Current School Building________________________________ 
School address _________________________________________________________________ 
School phone __________________________  School fax ______________________________ Guidance Counselor’s Name__________________________ Email________________________ Guidance Counselor’s Phone #______________________ Fax # _________________________ 
Reason for Referral: Please attach Superintendent hearing and current discipline records. 
Please list exact courses to be tutored including Spanish and PE: 
Please indicate how many science lab minute’s student has completed. _________ 
List Regent’s exams student will be taking: 
January: __________________________________________________________________ 
June: _____________________________________________________________________ 
What other state assessments will be given while student is in program? (i.e.; 8th grade ELA) _____________________________________________________________________________ 
Please attach student’s most recent report card. Please attach exit grades if student is leaving during the course of a marking period. 
Does student qualify for either free lunch ________ or reduced lunch_______? 
Does student have an IEP or 504 plan? (Please circle one and attach if applicable) 
If the student has an IEP or 504 plan, please list the teacher assigned to monitor student. Name_________________________ Email ____________________ Phone_______________ 
Please list student’s annual or triennial review date ____________________________________ 
Duration of Tutoring Placement: Begin Date _______________End Date _______________ Date when student should be reviewed to return to district ___________________________ 
Counselor’s Signature_______________________________ Date _______________________ Principal’s Signature________________________________ Date _______________________ 
Please make sure the following have been completed 
_____Student’s exit grades from home district _____Most recent Report card _____Free or reduced lunch form _____Student’s discipline records and Superintendent hearing findings _____Emergency contact form if possible _____IEP or 504 plan or psychological report if applicable 
Any additional notes regarding student. (Receives counseling, probation etc.)