Cloquet - New Student Form

Cloquet - New Student Form

Cloquet Staff only - Use this to report new students, returning students or "new to you" students.

Questions marked with an * are required

Case Manager Name *
 
Your email (if you want a copy of the data submitted sent to you via email):
 
Student First and Last Name *
 
State ID/MARSS #
 
Grade * 













 
Birthday
 (mm/dd/yyyy)
 
Gender
 Male 
 
Is the Student Latino?

 
Race - Check ALL that apply
 Native American / Alaskan Native 



 
Ethnicity - Check only ONE
 Native Ame/Alaskan Native
 Asian/Pacific Islander
 Hispanic
 Black, Non-Hispanic
 White, Non-Hispanic
 N/A
 
Primary Language other than English *
Yes
No
 

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
 
Parent's Address
 
Parent's City, State, Zip
 
Parent's Primary Phone
 
Relationship to Learner 

 
Have parental rights been terminated? * 

 
Is the student a Ward of the State? * 

 
Attending District* 
 

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
 
Primary Relationship 
 N/A 
 
Primary Address
 
Primary City, State, Zip
 
Resident District (resident district is determined by where the legal guardian lives not necessarily where the student lives). *
 
State Aid Category * 



 
Transportation District *
 
Transportation Category * 


 
Attending School * 


Cloquet High School
 Cloquet Middle School
 Washington
 
Adopting Existing IEP * 

 
Enrollment Start Date
 (mm/dd/yyyy)
 
Is this a new IEP/IFSP/IIIP? * 

 
Service Start Date *
 (mm/dd/yyyy)
 
Evaluation Status (SEES) * 
1 - Not evaluated, non-disabled, no IEP/IFSP regular education only2 - Shared-Time K-12 – Evaluated, EC – Evaluated
 3 - Evaluated – requires services but not yet in a program
Evaluated – receiving special education services (IEP/IFSP)
 5 - Evaluated – qualifies for services, parent refused
Evaluated – receiving services in district and receiving services through a public agency (IIIP)
 
Instructional Setting - Ages 6-21 *









 33 - EC or K Program (max 10 hrs/wk in this setting) 





 
Instructional Setting - Ages B-2 * 






 
Instructional Setting - Ages 3-5 *









 
Primary Disability * 













 

Early Childhood Only (B-K)

Evaluation Start Date
 (mm/dd/yyyy)
 
Evaluation End Date
 (mm/dd/yyyy)
 
Total Evaluation Hours
 
Comments
 
 
 I agree that the information provided on the form including legal name, birthdate, gender and race/ethnicity for this student is correct to the best of my knowledge. 
 

 

 



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