Form Dd-525 - Application For Eligibility Determination Page 3

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DD-525 (9-17) PAGE 3
NAME (Last, First, M.I.)
DATE OF BIRTH
CURRENT / PAST MEDICAL CONCERNS
(Describe any other disabling conditions or special considerations)
EDUCATIONAL HISTORY
District / School Contact
Type of Education Placement-504/ IEP
Date of Enrollment
LIST PROFESSIONALS THAT PROVIDED ALL QUALIFYING DIAGNOSIS
(i.e. neurologist, psychiatrist, development pediatrician, therapist )
Name, phone, email (Including credentials)
Type of Evaluation / Report
Date Completed

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