2024-25 - Request for Support, 504, or Special Education Evaluation

2024-25 - Request for Support, 504, or Special Education Evaluation
Para obtener ayuda con la traducción al español, envíe un correo electrónico a vasd-translators@verona.k12.wi.us o llame al
(608) 653-1019 or (608) 845-4491.
STUDENT INFORMATION
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
School*
Grade*
Name of Private/Parochial School in VASD Boundaries
REFERRAL DETAILS

If the answers to the majority of the questions below are "no," "none," or 'N/A," we recommend reaching out to your child's teacher or your school principal as a first step regarding additional support.
Have you connected with your child’s teacher/s about your concerns?*

YesNo
Have you reached out to your child's principal or other support staff about your concerns?*

YesNo
If Yes, please indicate who.
Has the student had an outside evaluation in any area of development? (check all that apply)*

Speech/LanguageHearingVisionPsychologicalDevelopmentalNoneOther
Please upload a copy of the outside evaluation if you have it.

Cancelof
Student has a formal personalized reading plan (per WI Act 20).

YesNoI don't know
List any confirmed medical diagnoses for your child.*
If none, enter N/A.
List any community supports you're currently working with to address your concerns (e.g., counseling, therapy, occupational therapy, speech, etc.)*
If none, enter N/A.
Describe what school-based programs, services, or interventions that have been tried to address the concerns above and the results of such programs, services, or interventions (including academic, behavioral, and/or assistive technology).*
If none, enter N/A.
What are some of your student’s strengths, interests or motivators?*
I am requesting contact from the school psychologist about additional support for my child.*

I’m interested in a conversation about support for my child at school.I'm interested in a Section 504 Plan evaluation.I'm interested in a Special Education evaluation.
Section 504 Plan Evaluation

I'm interested in discussing the possibility of a Section 504 Plan Evaluation.I know what a Section 504 Plan is and would like to begin an Section 504 Plan Evaluation.
Special Education Evaluation

I'm interested in discussing the possibility of a Special Education Evaluation.I know what an Individualized Education Plan (IEP) is and would like to begin a Special Education Evaluation.
Specific area(s) of concern. (check all that apply)*

AcademicBehavior/Social EmotionalCommunicationDevelopmental Delay (general delay in early learning skills, applicable to children in 4K or elementary)HearingMedical (physical/health)MotorSpeech/Language DevelopmentVisionOther
For each area listed above, please provide a detailed description or example of the concern. (e.g. “My child has had difficulty producing the ‘th’ and “f” sounds since age 4.”)*
If you have questions about our schools’ student support processes, please contact your student’s school psychologist.
ELECTRONIC SIGNATURE

The electronic signature below and its related field(s) are treated by Verona Area School District like a handwritten signature on a paper form (Board Policy 773, Use of Electronic Signatures).
I agree that the information provided herein is complete and accurate. I understand that this information is being used by the Verona Area School District for the purposes of potentially evaluating the student named above.
I agree to the above.*

Yes
Name of Person Completing Form*

First NameLast Name
Date*

MonthDayYear
Date
Student's Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Relationship to Student*

Parent/GuardianVASD School StaffOutside Provider (doctor, social worker, etc)Other
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please verify that you are human*
Should be Empty:

2024-25 - Request for Support, 504, or Special Education Evaluation

STUDENT INFORMATION

REFERRAL DETAILS

ELECTRONIC SIGNATURE