“SPECIAL EDUCATION REGISTRATION FORM”

Student’s Name: ______DOB ______

Has the student been enrolled in any special program?

Yes

/

No

/ A /Autism /

Yes

/

No

/ OHI / Other Health Impaired

Yes

/

No

/ ED / Emotional Disorder /

Yes

/

No

/ PT / Physical Therapy

Yes

/

No

/ HI / Hearing Impaired /

Yes

/

No

/ SLD / Specific Learning Disability

Yes

/

No

/ MIID / Mild Intellectual Disability /

Yes

/

No

/ SLI / Speech Language Impaired

Yes

/

No

/ MOID / Moderate Intellectual Disability /

Yes

/

No

/ SID/ Severe Intellectual Disability

Yes

/

No

/ OT / Occupational Therapy /

Yes

/

No

/ VI / Visual Impaired

Yes

/

No

/ DD/ Developmental Delay /

Yes

/

No

/ OTHER

For Preschool & Kinder New Students

Yes

/

No

/ AZIEP /

Yes

/

No

/ DD / Developmental Delay

Yes

/

No

/ DDD – Division of Developmental Disabilities /

Yes

/

No

/ SLI/ Speech Language Impaired

Yes

/

No

/ PHI / Preschool Hearing Impaired /

Yes

/

No

/ PVI / Preschool Visual Impaired

Yes

/

No

/ PSD / Preschool Severe Delay /

Yes

/

No

/ OTHER

YES NO

Does your child have any physical or mental problem that may affect his/her school work?

Does your child take medication on regular basis for a chronic illness or condition?

**If yes, contact District Nurse immediately prior to registration.

** Please be advised if the parent answered yes to any of these questions, please send them to the Special Education Department at the District Office with this form.

SCHOOL ASSIGNED TO:

ADES RCES GES SWJH

SLPS

CCES DVES EPES SLMS

Teacher Assigned to: ______

______

Parent Signature Date

______

Signature of the School Official Date

1/9/18 mg