Questions marked with an * are required |
Case Manager Name *
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Your email (if you want a copy of the data submitted sent to you via email):
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Student First and Last Name *
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State ID/MARSS #
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Grade * |
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Birthday (mm/dd/yyyy) |
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Residency is determined on where the legal guardian lives regardless of where the student lives. Enter parent or legal guardian information here. |
Parent's Name
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Parent's Address
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Parent's City, State, Zip
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Parent's Primary Phone
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Relationship to Learner |
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Have parental rights been terminated? * |
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Is the student a Ward of the State? * |
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Attending District* |
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If the student lives with someone other than the legal guardian, please answer the next set of questions (foster home, grandparent, friend, etc). |
Primary Name
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Primary Relationship |
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Primary Address
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Primary City, State, Zip
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Resident District (resident district is determined by where the legal guardian lives not necessarily where the student lives). *
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State Aid Category * |
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Transportation District *
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Transportation Category * |
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Attending School * |
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Adopting Existing IEP *
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Enrollment Start Date (mm/dd/yyyy) |
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Is this a new IEP/IFSP/IIIP? * |
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Service Start Date * (mm/dd/yyyy) |
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Evaluation Status (SEES) * |
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Instructional Setting - Ages 6-21 * |
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Instructional Setting - Ages B-2 * |
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Instructional Setting - Ages 3-5 * |
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Primary Disability * |
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Early Childhood Only (B-K) |
ECSE Class Placement? 3-5 ECSE Non District 3-5 Non District Speech 3-5 District ECSE B-3 Home Visits B-3 Child Care Center B-3 Home Speech N/A |
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Evaluation Start Date (mm/dd/yyyy) |
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Evaluation End Date (mm/dd/yyyy) |
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Total Evaluation Hours
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Comments |
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