Enrollment Information Sheet
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1SOUTH BEND COMMUNITY SCHOOL CORPORATION
Special Education Services
215 South St. Joseph Street, South Bend, Indiana, 46601
Phone: 574-283-8130 Fax: 574-283-8105
Enrollment Information Sheet
Student:_______________________________________ Date of Birth: __________________________
SBCSC ID#: ________STN#: ________________School: ____________________________________
Address: ___________________________________________________________________________
(zip)
Parent(s) Name: _____________________________________________________________________
Date Enrolled: ________________________________________________ Grade: ________________
Disability Area(s):
Primary:__________________________________________________________
Secondary: _______________________________________________________
Name of Teacher of Record: _______________________________________________________
(A TOR has a license or has applied for an Emergency Permit in the disability area of the student)
Student’s Previous School: _____________________________________________________________
If not SBCSC, please provide additional school information:
Address: ________________________________________ Phone: _____________________________
City:____________________________________________ State: ______________________________
Date of last IEP: ____________________Date of last Psychological Evaluation: ___________________
REMINDER:
1. Out of State IEP – Needs a Newly Enrolled Student form.
2. No current IEP – Need a signed Newly Enrolled Student form.
3. Current Indiana IEP – Need signed Permission for Special Education Services.
Please indicate how disability was verified: ________________________________________________
___________________________________________________________________________________
Verified by: ________________________________________________ Date:_____________________
Please attach appropriate parent permission and all available records to this form and send to
Special Education Services.
Copy to: parent, cum, TOR and original to Special Ed Services
10/1/13
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