Fields  marked by an * are required fields.

Add to IEP Software     (Please ask either your school psychologist or OCEC to add  a student, but not both.)

Add to Childcount Roster 

*Your Name:             

Date:

*Student Name (First, Middle, Last):  

*DOB:    *Entry/Initiation Date:  

Case Mgr:      *Grade Level Pre-K K 1 2 3 4 5 6 7 8 9 10 11 12

*Home School:   

*Serving School:

Parent Address (street, city, zip):  

Parent Phone Number:

Parent/Guardian Name(s):

Relationship:   

Comment:    

Use to Comment to note ethnicity if not white, a non- A Fund Code (orphanage, for example), or to give other pertinent info not covered in boxes above.   

IF STUDENT IS A MOVE-IN PROVIDE THE FOLLOWING:

Disabilities:   

Related Services:

Spec Ed %:   EE%:   

SIS #:  Medicaid #:  

If there are no plans to re-write the student's IEP within the next two weeks, please submit a copy of the current IEP to OCEC.