GOVERNMENT OF THE DISTRICT OF COLUMBIA

Child and Family Services Agency

2015-2016 EDUCATION INFORMATION FORM

Client Name: / FACES Client ID #: / Date of Birth

Contacts

Social Worker / Agency: / Social Worker: / Supervisor:
Placement Provider* / Name: / Address: / Phone Number(s):
Birth Parent #1 / Name: / Address: / Phone Number(s):
Birth Parent #2 / Name: / Address: / Phone Number(s):
Other Contacts / GAL: / AAG: / Education Attorney:

*For youth residing in a group home please write in the name of the facility and the best person to contact

Special Education

Child has an IEP / IFSP(Individual Family Service Plan (IFSP) is an early intervention planfor children aged 0-3 with developmental delays; IEP plans are developed for children with disabilities aged 3 and up)

Fill out the section based on the child’s age or status below:

Early Childhood (Ages 0-5)

AttendsPreschool
Attends Center-based daycare / Attends Home-based daycare
Does not attend daycare / school (explain)

School / Center / Provider

School / Center / Provider Name: / City, County, State:
Grade/Care Type: SelectPre K3 (DC)Pre K4 (DC)Pre K (outside DC)PreschoolHead StartDaycare / Type of School (choose one): Select TypePublic SchoolCharter SchoolPrivate School
This information has been entered into FACES and all previous school information has been end dated and closed out.

Enrolled in K-12

School Planning to Attend 2015-2016(Refer to School Enrollment Tip Sheet for other required documentation for enrollment)

School Name: / City, County, State:
Grade: SelectKindergarten123456789101112Ungraded / Type of School (choose one): Select TypePublic SchoolCharter SchoolNonpublic Day SchoolPrivate SchoolResidential Treatment FacilityHome School
This information has been entered into FACES and all previous school information has been end dated and closed out.

If different school than most recent school attended in 2014-2015 please select reason for change:(select all that apply)

Natural Transition(i.e.: middle school to high school)

Lottery Selection (DC)(*If youth participated in DC School lottery please also select reason youth participated in lottery)

Proximity to placement(i.e.: travel time to school from provider home was prohibitive)

Child Request(please exclude any requests based on proximity)

Parent / Guardian Choice(please exclude any requests based on proximity)

Services / Programs Availability(i.e. special education services, career academy services, etc.)

Residential Facility(i.e. residential treatment facility, youth services center)

Other

Education Decision Maker(Note that biological parents retain the right to make education decisions related to a child’s special education unless a court order terminates the parent’s right to make decisions):

One or both of the student’s biological parent(s) retain educational decision-making rights.

Parent 1 (above) maintains rights / Parent 2 (above) maintains rights

Another Individual Has Been Appointed to Make Education Decisions for the Child(i.e., surrogate parent, court-appointed education decision-maker, etc.) (Attach court order or other supporting documentation)

Name: / Address: / Phone: / Relationship to child:

The status of the decision-making rights of the student’s parent(s) is unknown.

Not Enrolled in K-12(select all that apply)

Graduated HS in select year201020112012201320142015
Dropped Out Last Grade Completed6 or below789101112
Completed GED Program select year201020112012201320142015 / Enrolled in GED Program
Enrolled in Vocational / Technical Program / Enrolled in College
Other

This information has been entered into FACES and all previous school information has been end dated and closed out.