Tipton Academy

SPECIAL EDUCATION INFORMATION
 
Student Name:__________________________________________________________ 
 
Date of Birth (mm/day/yr)                                          
Age                                                     
Grade 
 
Does your child qualify for Special Education?
Does your child have a current IEP?   
Does your child have a current 504 plan? 
 
Please check any boxes that apply to your child’s current educational needs And areas of weakness: 
 
Reading    Visual Impairment  Writing    Hearing Impairment  Math    Emotional Impairment  Speech/Language   Other Mental Impairment (Down’s Syndrome, etc.)  ADHD (Hyperactivity) Other_____________________________________________________________
 
Has your child been expelled in the past?   
Date(s):   
Reason(s):   
Has your child been retained?     
Which grade(s)  
 
Signature of Parent/Legal Guardian                                                                             
Date