CENSUS OF INFANTS, CHILDREN AND
YOUTH WHO ARE DEAFBLIND IN TEXAS
INSTRUCTIONS:
Please complete this form if you currently have no students who are deafblind to report and
return to the deafblind specialist at the Education Service Center in your region.
If this district serves as fiscal agent for a special education co-op, please list by name all
individual districts served that have no students to report. If the fiscal agent has students but
member districts do not, leave the line, "We at", blank and just fill in the member districts on the
lines at the bottom of the page. Please then submit completed registration forms for all districts
that do have students to report.
We at ,
in ESC Region __________,
have no students who meet the Federal criteria as deafblind to report.
Name:
Title:
Signature
Date:
Additional Districts Served by this Fiscal Agent with no students to report