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					                               Governor Livingston High School
                 Program for Students Who are Deaf and Hard of Hearing
                        175 Watchung Blvd ● Berkeley Heights ● New Jersey ● 07922


                                      Student Application


Student Information:
     Name: _______________________________________________         Grade: _______ Age: ________

     Address: ____________________________________________________________________________
                                               Street
              ____________________________________________________________________________
                           City                                       State        Zip

     Mother’s Name: _________________________      Father’s Name: _________________________

              Phone: _________________________             Phone: _________________________

              Email: _________________________             Email: __________________________


School District Information:
     District: ________________________________________________________________________________

     Current School: _________________________________________________________________________

     Address: _______________________________________________________________________________
                           Street                              City            State      Zip
     Case Manager: ____________________________________ Phone: _______________ Email: ________

Additional Comments: _________________________________________________________________________


                       _________________________________________________________________________



               Current reports required in order to be considered for admission:
                                  ______ Educational
                                  ______ Speech
                                  ______ IEP
                                  ______ Audiology/Cochlear Implant Mapping
                                  ______ Indication that the GEPA was/will be taken



 To begin the application process, please have the case manager contact Michele Gardner via email at
 mgardner@bhpsnj.org or call 908-508-1923 x1730. All current reports and this application should be
 sent to:
                          Michele Gardner, Supervisor of Special Education
                                         345 Plainfield Avenue
                                     Berkeley Heights, NJ 07922

				
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