Student Information Sheet Page 2
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1
2Student's
L ast
N ame
First
N ame
SIBLING
I NFORMATION
Complete
t his
s ection
o nly
i f
a pplicable,
i nclude
o nly
s iblings
w ho
a re
c urrently
i n
g rades
K -‐12
i n
t he
L ogan
C ity
S chool
D istrict
Full
N ame:
Grade:
Name
o f
S chool
A ttending:
Full
N ame:
Grade:
Name
o f
S chool
A ttending:
Full
N ame:
Grade:
Name
o f
S chool
A ttending:
Full
N ame:
Grade:
Name
o f
S chool
A ttending:
HOME
L ANGUAGE
S URVEY
SPECIAL
E DUCATION
A ND
S PECIAL
S ERVICES
S URVEY
What
i s
t he
p rimary
l anguage
s poken
i n
t he
h ome?
Please
p lace
a
c heck
n ext
t o
a ny
s ervices
y our
s tudent
w as
r eceiving
o r
h as
r eceived
( check
a ll
t hat
a pply).
English
Other
Special
E ducation
( see
b elow)
English
-‐
S econd
L anguage
S ervices
( ESL)
What
i s
t he
p rimary
l anguage
t he
s tudent
s peaks?
Gifted
P rogram
Title
1
English
Other
Speech
T herapy
Vision
I mpaired
What
l anguage(s)
d oes
y our
c hild
s peak
a nd
u nderstand?
Hearing
I mpaired
Section
5 04
English
Other
Type
o f
A ccommodation:
In
w hich
l anguage
d o
y ou
( the
p arent(s)/guardian(s)
p refer
t o
r eceive
Has
y our
s tudent
r eceived
S pecial
E ducation
s ervices?
Yes
No
future
c ommunication
f rom
t he
s chool?
During
t he
p ast
y ear?
Yes
No
English
Other
During
t he
p ast
t hree
y ears?
Yes
No
DISCIPLINE
S URVEY
If
y es,
e stimated
a mount
o f
t ime
s tudent
r eceived
S pecial
E ducation
s ervices
1/2
d ay
o r
l ess
( 0
t o
4
h ours)
More
t han
1 /2
d ay
o r
l ess
Student
I S
c urrently
s ubject
t o
a
d isciplinary
o rder
o f
a nother
l ocal
s chool
s ystem.
Is
t here
a ny
o ther
i nformation
y ou
w ould
l ike
t o
s hare
t hat
w ould
h elp
u s
b etter
s erve
Student
I S
N OT
c urrently
s ubject
t o
a
d isciplinary
o rder
o f
a nother
l ocal
s chool
your
s tudent?
Yes
No
system.
If
y es,
p lease
e xplain:
"Disciplinary
O rder"
m eans
a ny
o rder
o f
a
l ocal
s chool
s ystem
w hich
i mposes
s hort-‐
term
s uspension,
l ong-‐term
s uspension,
o r
e xpulsion
o f
a
s tudent.
If
y es,
p lease
e xplain:
Does
y our
s tudent
r equire
a ny
m edications?
Yes
No
If
y es,
p lease
l ist
t ype
o f
m edication(s):
MIGRANT
S URVEY
Are
y ou
n ow
e ngaged
i n
m igrant
w ork,
o r
h ave
y ou
b een
e ngaged
i n
m igrant
w ork
(agricultural,
f ishery,
m eat-‐packing,
a nd
c heese
( factory)
i n
t he
l ast
t hree
y ears?
Yes
No
STUDENT
H EALTH
I NFORMATION
Student
M edical
H istory
-‐
P lease
c heck
a ll
t hat
a pply
ADHD
o r
A DD
Yes
No
Heart
D isease
Yes
No
Asthma
Yes
No
Hemophilia
Yes
No
Bowel
o r
b ladder
p roblems
Yes
No
Multiple
S clerosis
Yes
No
Bone
o r
s pinal
p roblems
Yes
No
Muscular
D istrophy
Yes
No
Cancer
Yes
No
Neurological
i llness
Yes
No
Cystic
F ibrosis
Yes
No
Seizures
o r
C onvulsions
Yes
No
Diabetes
Yes
No
Vision
l oss/correction
Yes
No
Emotional
P roblems
Yes
No
Other
( please
d escribe):
Parent/Guardian
S ignature
( Required):
Date:
FOR
O FFICE
U SE
O NLY
Student
I D
N umber:
Start
D ate:
Immunizations
C ompleted
Referred
t o
S pecial
E d
Referred
t o
A LP
( ESL)
Copy
o f
B irth
C ertificate
Proof
o f
G uardianship
Proof
o f
R esidency:
Utility
B ill
Lease
o r
R ental
A greement
Vehicle
R egistration
Other:
Permit
t o
R egister
R equired:
Yes
No
If
y es,
d ate
d istrict
n otified:
Eligible
t o
p articipate
i n
M cKinney-‐Vento
P rogram:
Yes
No
If
y es,
d ate
d istrict
n otified:
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