SPECIAL EDUCATION INFORMATION
Date of Birth (mm/day/yr)
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?
Has your child been retained?
Signature of Parent/Legal Guardian