Dd Form 2792-1, Exceptional Family Member Special Education/early Intervention Summary

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The DD Form 2792-1 is completed to identify a
family member with special educational/early
intervention needs.
DD Form 2792-1 is completed by the parents and
school or early intervention staff. Only this form
should be provided to school or early intervention staff.
Items 1 - 7 (Completed by sponsor or spouse).
Do not include medical information forms that may be
used for EFMP screening or enrollment.
Item 1.a. Application Status (X one).
Initial Screening/Enrollment - First Exceptional Family
Items 1 and 2 are completed by parents. The
Member (EFM) application for the family member
remainder of this form is completed by school or early
intervention staff.
Updated Information - Update to a previous EFM
evaluation for the family member noted.
Item 1.a. Release of information. Sponsor name.
Request Disenrollment - Used to disenroll a child
Self-explanatory. Completed by sponsor, spouse, or
when he/she no longer requires special education or
student who has reached the age of majority.
early intervention services, or when the child no
longer qualifies as a dependent.
Item 1.b. Rank. Enter the sponsor's rank.
Item 1.b. Family Status. Place an "X" in the box if
Item 1.c. Sponsor SSN. Enter the sponsor's social
there are any other family members who have been
security number.
identified as EFMs.
Item 1.d. Signature of sponsor, spouse, or student
Items 2.a. - k. All items refer to sponsor.
who has reached the age of majority.
Self-explanatory. Sign and date before providing form
to school or early intervention program.
Item 3. Answer Yes if the sponsor was assigned to
current duty station for compassionate reasons,
Item 1.e. Date signed. Self-explanatory.
e.g., to ensure that a family member receives health
care at a major medical treatment facility.
Items 2.a. - e. Child information. Self-explanatory.
Answer No if the sponsor is not currently assigned
Completed by sponsor or spouse.
for compassionate reasons.
Items 3.a. - e. EIP/School information. Completed by
Answer Yes if both spouses are on active
EIP or school personnel. Mark (X) Yes or No for each
tem 4.
duty; otherwise answer No.
item. If Yes is marked in Items 3.b. or c., remainder of
If Yes, complete Items 4.a. - c.
form must be completed.
tem 5.a. Exceptional family member name. Enter
Items 4.a. - b. Eligibility criteria. Mark only one.
name for the family member for whom this form will
(Codes in 4.a. are for Army coding only.)
be completed.
Item 4.c. Identify the disability, if known. (For
Item 5.b. Relationship to sponsor. (Son, daughter,
example, blindness, autism, PDD.)
Item 5. Severity. Mark only one.
Item 5.c. Date of birth. Self-explanatory.
Item 6. Provider/school official information.
Item 6. Self-explanatory.
Self- explanatory.
Item 7. Is family member enrolled in DEERS?
Military only. Self-explanatory.
DD FORM 2792-1, SEP 2003
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