**This is a 2 page application. Both pages will need to be filled out for prompt process.**

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* 1. Student's Name

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* 2. Gender

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* 3. Date of Birth

Date

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* 4. Home Language

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* 5. # of Adults & Children in Home

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* 6. # of children in home

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* 7. Does the child have a current IEP or IFSP? (Child is receiving services through the school system or Early Steps)

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* 8.  First - PARENT/LEGAL GUARDIAN living in home WITH Child

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* 9. Second - PARENT/LEGAL GUARDIAN living in home WITH Child (if not in home leave blank)

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* 11. What school system are you zoned for? (even if your child is not school age)

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