Northern Lights Special Education Cooperative

Quality Education Through Cooperation and Partnership

All Other Districts - Use this to report new students (Birth through grade 12).

Questions in Bold and 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*

Address

City, State, Zip

Birthdate  (mm/dd/yyyy)

Gender   Male   Female   N/A

MARSS # (13 digits)

Grade  Pick from ListECK123456789101112

IEP/IFSP/IIIP Start Date:  (mm/dd/yyyy)

Attending District Pick from ListBarnumCarltonCloquetCromwell-WrightEskoHermantownLake SuperiorMcGregorMoose LakeNorthern Lights AcademyProctorWillow RiverWrenshall

Building

Resident District

Primary Disability  Pick from List00 - No IEP/IFSP/IIIP, non-disabled student01 - 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 Pick from List00 - No IEP/IIIP01 - 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/Hospital11 - Designed for Children with development delays12 - Designed for typically developing children13 - Home14 - Hospital (inpatient)15 - Residential Facility16 - Service Provider Location17 - Other Setting31 - EC or KG program at least 10 hrs/week with services in setting32 - EC or KG program at least 10 hrs/week with services in another location33 - EC or KG program up to 10 hrs/week with services in setting34 - EC or KG program up to 10 hrs/week with services in another location41 - Separate class42 - Separate School43 - Residential facility44 - Service provider location45 - Home

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(s)   Guardian   Foster Parent(s)   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(s)   Guardian   Foster Parent(s)  Other:   N/A

Comments

 

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