Private School - Special Education Evaluation Request Form

Private School - Special Education Evaluation Request From
Complete this form only if your child attends one of the two state-recognized private or parochial schools within VASD boundaries:

Bright Child Learning Center or Impact Christian Academy.

Para obtener ayuda con la traducción al español, envíe un correo electrónico a vasd-translators@verona.k12.wi.us.
STUDENT INFORMATION
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
School
Grade
Student's Home Address

Street Address

Street Address Line 2

CityState

Zip Code
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?
Have you reached out to your child's principal or other support staff about your concerns?
If Yes, please indicate who.
Has the student had an outside evaluation in any area of development? (check all that apply)

Other
Please upload a copy of the outside evaluation if you have it.

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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 Verona Area School District about additional support for my child.
Specific area(s) of concern. (check all that apply)

Other
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.”)
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.
Name of Person Completing Form

First NameLast Name
Date

MonthDayYear
Date
Relationship to Student

Other
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please verify that you are human
Should be Empty:

Private School - Special Education Evaluation Request From

STUDENT INFORMATION

REFERRAL DETAILS

ELECTRONIC SIGNATURE