Preschool Guardian Referral for Special Education

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Please provide the following information and someone will contact you regarding next steps for the referral for special education. Please do not complete this form multiple times. If you have additional questions regarding your request, please call the Exceptional Education Office at 205-402-5316. Once all three steps have been completed (this form, the enrollment form and submission of documents) please allow 5 business days to verify enrollment. At that time, someone will contact you.

Email *

Student Name (First & Last) *

Student's Date of Birth *

YYYY

Guardian Name(s) *

Guardian Phone Number(s) *

Student's Zoned School *

East

West

Dolly Ridge

Cahaba Heights

Liberty Park

Not Sure

Has your child previously been evaluated or received services from a community agency/clinic? If yes, please email a copy of the most recent report to Sara Katherine Janecky at janeckys@vhcs.us *

Yes

Did your child receive Early Intervention Services? *

Yes

What concerns do you have for your child? (Check all that apply) *

Speech (Pronunciation of words)

Language (ability to understand or use spoken language)

Motor: Difficulty with fine motor or gross motor skills (walking, running, coloring)

Adaptive: Difficulty with self-help skills (feeding, toileting, dressing)

Cognitive: Difficulty with learning (learning colors, letters, simple kids songs)

Social/Emotional: Difficulty with peers (does not play with peers/siblings, behavior difficulties)

Other:

Required

Please describe your concerns noted above *

Is your child enrolled in a preschool? If so, please list name of preschool and contact information. If not, put NA *

Enrollment into VHCS must occur prior to the evaluation process. Please upload the following documents so that the enrollment verification process can occur. Once enrollment is verified, you will be contacted to discuss the referral process. VHCS Enrollment: You will select Sp Ed Private School instead of one of the zoned campuses.

Alabama Certificate of Immunization
Proof of age, to include but not limited to: birth certificate; religious, hospital, or physician's documents showing date of birth; a baptismal certificate or entry in a family Bible; an adoption record; an affidavit from a parent; previously verified school records, etc.
Current and valid lease, warranty deed, settlement statement, mortgage statement, or current property tax notice
A power bill in your name for the current month showing your residence's property address
One other item that ties you to the residence:
1. Proof of residency from the County Registrar of Voters
2. Current vehicle registration showing residence address
3. One other bill mailed to you at residence address
If legal custody of a child is split between two parents, you must attach a certified copy of the court order identifying each parent's respective award of physical custody.

If you have completed this form, and completed the linked enrollment form above, you must also submit the documents noted above by dropping them off at the BOE Annex:

1975 Merryvale Road- Vestavia, AL
OR
Email them to petersonlc@vhcs.us

The evaluation process will not begin until all 3 steps are completed. If you have questions, please email Sara Katherine Janecky at janeckys@vhcs.us

Thank you!

Please enter the date below as your signature for this form.

YYYY

A copy of your responses will be emailed to the address you provided.

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