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