Special Education Admission Checklist Form Template

Parent/Guardian Full Name

First NameLast Name

Parent/Guardian Email Address

example@example.com

Parent/Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Child's Full Name

First NameLast Name

Child's Date of Birth

Date

Child's Gender

Does the child have any diagnosed disabilities or special needs?

Please specify any other diagnosed disabilities or special needs.

Has the child previously attended special education programs?

If yes, please provide details about previous programs attended.

Does the child require any assistive devices or accommodations?

Please specify the assistive devices or accommodations needed.

Are there any specific behavioral or emotional considerations to be aware of?

Please describe any behavioral or emotional considerations.

Has the child undergone any recent assessments or evaluations?

Please upload copies of recent assessments or evaluations if available.

Parent/Guardian Signature