Stephen Decatur High School
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ADDITIONAL SERVICES copy to: _____File _____Special Ed _____Nurse
STEPHEN DECATUR HIGH SCHOOL Registration Questionnaire
Student Name______
DOB______Grade______
Name and Address of Last School Attended______
______
Has he/she ever received any of the following Special Education Services?
Yes No a. Speech Therapy ______b. Physical Therapy ______c. Resource Room ______d. Learning Disability Class ______e. Counseling/Mental Health Services ______
If yes to any of the above, when were services received?______
Who diagnosed the disability?______(E.g. school psychologist, medical doctor, and special ed teacher)
Who should be contacted to learn more about your son/daughter and his/her disability?
______
Have you provided us with a copy of your child’s IEP/504 plan?______
Does your child have any medical issues? If yes, please explain______
______
05/30/2008KH