SE Student Data Card
Teacher of Record *
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Student First Name *
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Student Last Name *
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Student Date of Birth
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DD
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Student Testing Number (STN)
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LRE Number
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Primary Eligibility
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Secondary Eligibility
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Related Services (Check all that apply)
Date of Conference
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DD
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YYYY
Select the Purpose(s) (Check all that apply)
Special Comments or Concerns
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