ANW Special Education Interlocal: ESY Student Enrollment Form
Please use this form to enroll a student to attend the ESY program. Please note that this service must be included in the child's IEP.
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Email *
Student Name
Student's Age
Student's Grade (Current Year)
IEP Date
MM
/
DD
/
YYYY
Primary Exceptionality
Home District
Building of Attendance
Behavior Intervention Plan on IEP?
Clear selection
Individual Health Care Plan on IEP?
Clear selection
Allergies not listed on IHCP? (food allergies to note for snack time)
Please describe any toileting issues/support this student may have/need
Parent Contact - Name
Parent Contact - Phone Number
Parent Contact - Alternate Phone Number
Parent Contact - Address (for mailing purposes)
Emergency Contact-Name & phone number
ESY will be serving breakfast and lunch. If this child will NOT participate in this program, please check here
Please specify any special dietary/feeding requirements (feeding tube, puree'd meals ect)
Pick Up address (please include city)
Drop off address (if different than pick up)
Daycare Provider Name and phone number (if applicable)
Is there a bus aide listed on the IEP? *
Local  districts  provide  transportation  to  ESY.  Please  check  this  box  if  the  PARENT  will transport  the  student  to/from  ESY
Does the student have any of the following related services listed on the IEP for ESY? Please note that this does not mean they receive the exact same services at ESY as the regular school year. If you are unsure if the service is needed, please ask the service provider
Please describe the frequency and duration of the above mentioned related services. Once a week
Please describe any assistive tech devices that are used by the student, who owns the device and who it should be returned to at the conclusion of ESY. Also, please include any passcode's necessary to access the device.
Please provide any ideas of reinforcers or preferred activities of the student
Please provide your summer contact info in case of any questions
Due to the fact that IEP's are held at many different times during the year, it is important to  follow  up  with  parents  to  make  sure  they  are  aware  of  the  specific  dates  of  ESY  and that  their  child  is  being  enrolled  in  the  program
A copy of your responses will be emailed to the address you provided.
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