Parent/Guardian Name: Phone: Email: Section 1A: K-12 Student Profile Student Name: MSIS Number: School: District: Date of Birth: Grade Level: Gender: Race: Street Address: Course Performance Behavior Instructions: If student is elementary: Indicate recent term grades in this table. Instructions: Check if documentation is applicable & available. If student is secondary: Indicate recent SATP course grades. Instructions: Attendance Special Population Retention School Year Days Present / Absent Instructions: Check if applicable to student. Instructions: If applicable, indicate and school year(s) below. Special Education / IEP Grade School Year List last 3 schools attended and dates. 504 ELL (complete Appendix B) Dyslexia Speech/Language Universal Screener Promotion Act (K-12) Universal Screener Instructions: Indicate score and (Secondary) Instructions: Fill in only if student completed 3rd grade after screener used for each. implementation of Literacy-Based Promotion Act (2014-2015) Algebra 1 English II (If student fails all three attempts, see Appendix E to see if student qualifies for Good Cause Exemptions) Biology Dyslexia Screener Hearing/Vision Screener Instructions: Indicate pass/fail. If fail, begin tiered interventions U.S. History Reading K-Readiness Assessment Recommended 530 If additional school screener(s) were used, attach Form Completed By: Date of Completion: student score reports.
Section 1A: K-12 Student Profile Student Name: MSIS Number: School: District: Date of Birth: Grade Level: Gender: Race: Parent/Guardian Name: Phone: Email: Street Address: Course Performance Instructions: If student is elementary: Indicate recent term grades in this table. Instructions: If student is secondary: Indicate recent SATP course grades. Behavior Instructions: Check if documentation is applicable & available. Attendance School Year Days Present / Absent List last 3 schools attended and dates. Retention Instructions: If applicable, indicate and school year(s) below. Grade School Year Special Population Instructions: Check if applicable to student. Special Education / IEP 504 ELL (complete Appendix B) Dyslexia Speech/Language Promotion Act Instructions: Fill in only if student completed 3rd grade after implementation of Literacy-Based Promotion Act (2014-2015) (If student fails all three attempts, see Appendix E to see if student qualifies for Good Cause Exemptions) Universal Screener (K-12) Instructions: Indicate score and screener used for each. Universal Screener (Secondary) Algebra 1 English II Biology U.S. History Reading If additional school screener(s) were used, attach student score reports. Dyslexia Screener Instructions: Indicate pass/fail. If fail, begin tiered interventions Hearing/Vision Screener K-Readiness Assessment Recommended 530 Form Completed By: Date of Completion: