Request for Alternative Education Services

REQUEST FOR ALTERNATIVE EDUCATION SERVICES

2935 Universal Court
Oshkosh WI  54904
Phone: 920-233-2372 - Fax: 920-424-4378

1.
*

Legal Name of Student:

2.
*

Gender:

Male
Female
3.
*

DOB (M/D/Y):

4.
*

Grade:

5.
*

School District:

6.
*

School of Attendance:

7.
*

Name of Parent/Legal/Guardian:

8.
*

Address:

9.
*

City/State/Zip:

10.
*

Phone Number:

11.

Cell Phone #:

 

DISTRICT CONTACT INFORMATION:


 

12.
*

Alternative Program Placement requested:

(1 required)
Alternative EBD program
  At-Risk program
13.
*

Type of Service Requested:

(1 required)
Student Evaluation
Student Re-Evaluation
Consultation
Transfer Student Needing Services
Other
14.

If "Other" is checked above, please indicate here the type of service requested:

15.
*

The E-Team has identified the following disability(ies);

(1 required)
AUT
  CD
  EBD
  HI
  LD
  OI
OHI
  SDD
  SL
  TBI
  VI
16.
*

The E-Team has identified the following Related Services:

(1 required)
Audiology
  Counseling
  Interpreter
  O&M
  OT
  PT
Social Work
  Transporation
  Other
17.

If OT or PT is checked above for Related Services, please indicate here the amount and frequency:

18.

If Other is checked above for Related Services, please explain here:

19.

Other Comments/Notes:

20.
*

Name of Contact Person:

21.
*

Email for Contact Person:

22.
*

Phone for Contact Person:


LEAs requesting enrollment in CESA 6 programs are required to include copies of the followingin the student's file:


 

23.
*

Date of signed parental consent for evaluation:

24.
*

Date of current Evaluation Team Summary report:

25.
*

Beginning Date of current Individualized Education Program (IEP):

26.
*

Ending Date of current Individualized Education Program (IEP):

27.
*

Date of signed parental or adult student consent for placement:

28.
*

Home district Case Manager and contact information:


 

HEALTH INFORMATION:

29.
*

Does the student have any chronic health conditions (such as: Diabetes, Asthma, Migraine headaches, seizures)?

30.
*

Does the student have any potential life threatening allergies (such as food, bee, or other)?

31.
*

Does the student take medication at school on a daily basis? If yes, please explain.

32.
*

Does the student currently have school health on his/her IEP?

Yes
  No

 

33.
*

Name of person submitting this i-form:

34.
*

Name of District Designee/Director (designated to allocate funds)

* Enter Your Email Address:

I am not a Robot

  

  • Main Office & All Mail:
  • 2935 Universal Ct
  • Oshkosh, WI 54904
  • Phone: 920-233-2372
  • Fax: 920-236-0580
  • Conference Center
  • 2300 State Road 44
  • Oshkosh, WI 54904
  • Phone: 920-233-2372
  • Fax: 920-424-3478