WCECC PreK New Student Enrollment Form
FOR STAFF USE ONLY!!! IF YOU ARE A PARENT INTERESTED IN PRE-K, CALL 993-2138.

--This should only be used for PreK and Early Childhood Staff Members receiving a new student.
Student's FULL Name: First, Middle, Last *
Do not use nicknames or initials - full legal name is required.
Does this child have an IEP? *
Do not use this form for Referrals - Do not use this form when moving from Speech IEP
Resident District - Where does child live? *
Student's Date of Birth *
MM
/
DD
/
YYYY
Student's Gender *
Enrollment Date *
What is the first day this student attending YOUR school?
MM
/
DD
/
YYYY
Student's Ethnicity *
Ethnicity/Race as recognized by ISBE reporting
SIS Number
MEDICAID #
Guardian's Name *
Include First, Last Name
Address *
Include Street Address and City
Phone *
Include multiple phones if available - if no phone - please write no phone
Serving School - Where will the child be attending? *
Session Attended *
DATE of Last Evaluation
MM
/
DD
/
YYYY
Date of Last IEP
MM
/
DD
/
YYYY
Case Manager
Students Primary Disability
Students Secondary Disability
Percentage of Time General ED
Percentage of Time Special Ed
Previous School Attended
Brechts Data Base
Does the Student Receive Related Services please describe
Person completing form - enter your email address *
EMAIL
Submit
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