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.
Student's Grade (Current Year)
LD-Specific Learning Disability
OH-Other Health Impairment
TB-Traumatic Brain Injury
USD 101- Erie/Galesburg
USD 256-Marmaton Valley
USD 366-Yates Center
Building of Attendance
Behavior Intervention Plan on IEP?
Individual Health Care Plan on IEP?
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
This child will NOT get breakfast and lunch at the ESY program
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
YES, parents will transport the student and the district does NOT need to be contacted to provide transportation
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
By checking this box, I confirm that I have spoke to the parents recently in regards to this student's enrollment in ESY
A copy of your responses will be emailed to the address you provided.
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