Sevier County Special Education
Extended School Year Program 2011
Student Information Form
Student’s Name ________________________School _______________
Teacher_______________Grade______Age_____Certification_________
Reading grade level _____________ Math grade level ________________
Developmental level (CDC students)______________________________
ESY _______________Speech only _________ Both ________________
Number of days attending per week ________ for:
2 weeks ____ 3 weeks ____ 4 weeks ____
Bus transportation needed: YES _________ NO ____________________
Parent’s Name ________________________________________________
Address _____________________________________________________
Phone - Home ______________ Work _____________Cell ____________
Medical Information ___________________________________________
Send Medical Notebook, if one is used, to Sped Office at end of school year.
Food Limitations _____________________________________________
Behavior Plan (include if there is a plan)
_____________________________________________________________
Comments __________________________________________________
_____________________________________________________________
_____________________________________________________________
FAX or E-MAIL: This Information Form and the Transportation Form,
TO DR. KAYE THOMAS
453-3112 by May 20, 2011
(Do not send copies of the IEP)