New Student Enrollment Form
Student's FULL Name: First, Middle, Last *
Do not use nicknames or initials - full legal name is required.
IEP Type *
Resident District *
Student's Home School *
Where would this child go to school if he/she was in general education? List name of SCHOOL, not the district.
Student's Date of Birth *
MM
/
DD
/
YYYY
Student's Gender *
Enrollment Date -- Date IEP services began at YOUR School *
What is the first day this student attending YOUR school? If student has been enrolled all year but initial IEP begins January, the enrollment date/ start date is JANUARY.
MM
/
DD
/
YYYY
Student ID# (SIS)
This is a nine digit state ID number. Please ask building secretary if you are unable to locate the ID.
Medicaid # (if available)
Student's Ethnicity *
Ethnicity/Race as recognized by ISBE reporting
Current Grade *
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
Parent Email Address (to send draft documents in the future) *
Date of last evaluation
MM
/
DD
/
YYYY
Date of last IEP
MM
/
DD
/
YYYY
Serving School *
List the name of the school the child will be attending this school year
Case Manager *
Include First, Last Name
Student's Primary Disability
Student's Secondary Disability
Percentage of Time in General Education
As stated on current IEP
Percentage of Time in Special Education
As stated on current IEP
Previous School Attended by student
List name of school, city, state
Brecht's Database (GUS) used at previous school?
Clear selection
Does this child receive Speech, OT/PT/Vision or Hearing services? *
Please notify Related Service Providers if you indicate.
Required
Enter your email address for confirmation (check it for accuracy) *
Please type YOUR first, last name
Submit
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