Student Profile - PDF
(153 KB)
A Name of Student
Last Name __________________First___________Middle_________
Date of Birth Month_____ /Day_____/Year
Gender ___ Male ____Female
Date of CSE Recommendation for Residential Placement
Month____ /Day____ /Year _____With consent of parent, has the CSE made a referral to the Office for People with Developmental Disabilities (OPWDD)? __ Yes __ No __ N/A
Parent ___ Legal Guardian ___
Last Name____________________________ First_______________________
Address Street_______________________________
City_______________ County___________________ State_____ Zip______
Home Telephone Number
( ) ___________
Work Telephone Number
( )
____________
School District
District Contact - Last Name ____________________First________________
Title _______________________________________
Address - Street ______________________________
City ______________ County
________________ State________ Zip __________ Telephone Number ( )Fax Number ( )
B Request for Out-Of-State Placement:
Signature, CSE Chairperson
Date
C Name of Current Educational Program (not proposed program):
(Please check the appropriate box below)
D CSE Classification:
(Please check one box to indicate the primary disability classification made by the CSE)
E Student Functioning Level: Results of Latest Test of Intelligence
(Check the box that most closely indicates the results)
Intellectual ability
Adaptive FunctioningLanguage Functioning
Interpreter Needed:
Does this student require a sign language interpreter? ___ Yes ___ No
Does this student require instruction in Braille and the use of Braille? ___ Yes ___ No
Does this student require bilingual education? ___ Yes ___ No
Native Language:
Physical Functioning:
Vision:
Hearing:
Mobility:
Medical Diagnosis: (Indicate any medical problems which may impact on the education of the child)
Medical Needs:
Does this child have medical needs beyond the administration of medications which require daily individualized attention from health care staff? __ Yes __ No
Does this child require 24 hour nursing care? __ Yes __ No
Please specify any medical alerts: _____________________
Behaviors Exhibited:
Behavior Frequency:
F Related Services Recommended:
G Diploma goal: