Northern Lights Special Education Cooperative

Quality Education Through Cooperation and Partnership

Hermantown Staff only - Use this to report new students (grades 1 through 12).

Questions in Bold and with an * are required

IEP/IIIP Manager Name

Your email (if you want a copy of the data submitted sent to you via email):

Student First and Last Name*

Address

City, State, Zip

D.O.B.  (mm/dd/yyyy)

Gender   Male   Female   N/A

MARSS # (13 digits)

Grade  Pick from List123456789101112

Student New to District w/Current IEP Enrollment Date:  (mm/dd/yyyy)

Type of Plan   4 - IEP  6 - IIIP   N/A

Initial IEP/IIIP Parent Signature Date  (mm/dd/yyyy)

Primary Disability  Pick from List01 - Speech/Language02 - DCD Mild/Moderate03 - DCD S/P04 - Physically Impaired05 - Deaf/Hard of Hearing06 - Visually Impaired07 - SLD08 - EBD09 - Deaf-Blind10 - Other Health Disabilities11 - Autism Spectrum Disorder12 - Developmental Delay14 - Traumatic Brain Injury16 - Severely Multiply Impaired54 - 504 Plan

Federal Instructional Setting (School Age Students 6-21)  Pick from List01 - Outside of regular classroom less than 21% of school day02 - Resource room between 21% and 60% of the day03 - Separate classroom more than 60% of the day04 - Public separate day school greater than 50% of the day05 - Private separate day school greater than 50% of the day06 - Public Residential Facility07 - Private Residential Facility08 - Homebound/Hospital33 - EC or K Program (max 10 hrs/wk in this setting)34 - EC or K Program (max 10 hrs/wk in another location)41 - Separate Class42 - Separate School43 - Residential Facilities44 - Service Provider Location45 - Home

Special Transportation?   Yes   No  N/A

Building

Resident District

Open Enrolled?   Yes  No   N/A

Foster Placement?   Yes   No   N/A

Contact # 1 Name

Contact # 1 Address

Contact #1 City, State, Zip

Contact # 1 Home Phone

Contact # 1 Cell Phone

Contact # 1 Email

Relationship to Learner (Contact #1)   Parent   Guardian   Foster Parent   Other:   N/A

Contact #2 Name

Contact #2 Address

Contact #2 City, State, Zip

Contact #2 Home Phone

Contact #2 Cell Phone

Contact #2 Email

Relationship to Student (Contact #2)   Parent   Guardian   Foster Parent   Other:   N/A

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