Hermantown - Early Childhood New Student Form (Birth-HK)

Hermantown - Early Childhood New Student Form (B-HK)

Hermantown Staff only - Use this to report new students for students ages birth through 2 and ages 3-HK.

Questions in Bold and with an * are required

IEP/IFSP/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 

 
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
 
MARSS # (13 digits)
 
Grade 

 

Class Placement?
#1300 3-5 ECSE Non District
#1500 3-5 Non District Speech
#1700 3-5 District ECSE
#1900 B-3 Home Visits
#2000 B-3 Child Care Center
#2100 B-3 Home Speech
NA

 

Foster Student?
Yes
No
NA

If yes to foster student, are parent rights intact?
Yes
No
NA

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

 
Initial IEP/IFSP/IIIP Parent Signature Date
 (mm/dd/yyyy)
 
Primary Disability 
 
Federal Instructional Setting (Birth - Age 2) 
 
Federal Instructional Setting (Age 3 - Age 5) 
 
Federal Instructional Setting (School Age Students 6-21) 
 
Special Transportation? 

 
Building
 
Resident District
 
Open Enrolled? 

 
Foster Placement? 

 
Parental Consent for Evaluation 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)

 
 
Evaluation Start Date
 (mm/dd/yyyy)
 
Evaluation End Date
 (mm/dd/yyyy)
 
Total Evaluation Hours
 
Parent Consent Date
 (mm/dd/yyyy)
 
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) 



 
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) 



 
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