2023 2024 K8 Educational Needs Form

This form is to be completed ONE PER STUDENT and only for students who have educational needs. Required fields marked with an asterisk *

First & Last Name of Parent Completing this Form*

Answer required for "First & Last Name of Parent Completing this Form"

Phone Number of Parent Completing this Form*

Number Required

Email of Parent Completing this Form*

Answer required for "Email of Parent Completing this Form"

Student Last Name*

Answer required for "Student Last Name"

Student First Name*

Answer required for " Student First Name"

2023-2024 Grade Level*

Answer required for "2023-2024 Grade Level"

Does your child need any special arrangements resulting from physical conditions such as visual impairments, hearing Impairments, medical conditions, or other physical disabilities?*

Answer required for "Does your child need any special arrangements resulting from physical conditions such as visual impairments, hearing Impairments, medical conditions, or other physical disabilities?"

In the space provided, please describe the condition requiring special arrangements and the arrangements needed.

Answer required for "In the space provided, please describe the condition requiring special arrangements and the arrangements needed."

In order to understand your child’s educational needs, we need to know if your child has ever been evaluated due to learning difficulties by a public school district, a private agency, or a private practice professional. Examples of agencies and individuals who perform educational evaluations include your local public school district, the Archdiocesan Department of Special Education, and private practice physicians and psychologists.

If YES, Approximate Date of Evaluation

Answer required for "If YES, Approximate Date of Evaluation"

Name of Evaluating Agency

Answer required for "Name of Evaluating Agency"

City

Answer required for "City"

The evaluation determined that my child has:

Please check all that apply.

Answer required for "The evaluation determined that my child has:"

Learning disability

Speech impairment

Language impairment

Hearing impairment

Emotional disorder

Attention deficit/hyperactivity disorder

Behavioral disorder

Gifted

Other:

If Other, please use this space to explain diagnosis.

Answer required for "If Other, please use this space to explain diagnosis."

Does ICD School have a copy of the evaluation report that includes the existing diagnosis?*

Answer required for "Does ICD School have a copy of the evaluation report that includes the existing diagnosis?"

If NO, please submit a copy of this evaluation report: bring to school office, email to [email protected] , or you can mail a copy to: ICD School Resource Department, 2089 Hanley Rd., Dardenne Prairie, MO 63368

If yes, please indicate the School District where your child is receiving services:

Answer required for "If yes, please indicate the School District where your child is receiving services:"

Wentzville School District

Francis Howell School District

Fort Zumwalt School District

Name of the school providing services in district selected above

Answer required for "Name of the school providing services in district selected above"

If Yes, please indicate the type of services your child is receiving.

For example: Speech therapy

Answer required for "If Yes, please indicate the type of services your child is receiving."

Please indicate the day and time your child is scheduled for these services

For example: Mondays at 3:45pm

Answer required for "Please indicate the day and time your child is scheduled for these services"

Contact Person at the Public School

For example: Mrs. Jane Doe, Speech Therapist

Answer required for "Contact Person at the Public School"

If your child’s services have been terminated, please submit a copy of current IEP or letter from the district stating your child has been staffed out of the service: bring to school office, email to [email protected] , or you can mail a copy to: ICD School Resource Department, 2089 Hanley Rd., Dardenne Prairie, MO 63368

Please use the following space for additional information you would like to provide.

Answer required for "Please use the following space for additional information you would like to provide. "

Please fix the highlighted areas below before submitting.

2023 2024 K8 Educational Needs Form