Home Phone (Including Area Code) Disabilities: (Check One) Mobile Phone (Including Area Code) 0 Not disabled 1 Mental retardation – – E-mail Address 2 Hearing impaired, including deafness – Secondary E-mail Address 4 Speech or language impaired – 5 Visually impaired, including blindness – Emergency Contacts - Please provide four (4). 6 Seriously emotionally disturbed – 1) Name Relationship 7 Orthopedically impaired 8 Other health impairment – – 9 Specific learning disability B Autism C Head injuries Phone Number – – – 2) Name Relationship Adult Offender: (Check One) Yes No Phone Number Juvenile Offender: (Check One) Yes No 3) Name Relationship Secondary Education: (Check One) Phone Number 1 Received high school diploma 2 Received high school equivalency – – 4) Name Relationship 3 Did not receive high school diploma or equivalent – Phone Number Post Secondary Education: (Check One) 1 None 2 Some 3 Associate – – – Daycare Name 4 Baccalaureate 5 Masters 6 Doctoral – – – Daycare Number Schools Attended (Post High) and training received: Number of Other Dependents ___
Home Phone (Including Area Code) Mobile Phone (Including Area Code) E-mail Address Secondary E-mail Address Emergency Contacts - Please provide four (4). 1) Name Relationship Phone Number 2) Name Relationship Phone Number 3) Name Relationship Phone Number 4) Name Relationship Phone Number Daycare Name Daycare Number Number of Other Dependents ___ Disabilities: (Check One) 0 – Not disabled 1 – Mental retardation 2 – Hearing impaired, including deafness 4 – Speech or language impaired 5 – Visually impaired, including blindness 6 – Seriously emotionally disturbed 7 – Orthopedically impaired 8 – Other health impairment 9 – Specific learning disability B – Autism C – Head injuries Adult Offender: (Check One) Yes No Juvenile Offender: (Check One) Yes No Secondary Education: (Check One) 1 – Received high school diploma 2 – Received high school equivalency 3 – Did not receive high school diploma or equivalent Post Secondary Education: (Check One) 1 – None 2 – Some 3 – Associate 4 – Baccalaureate 5 – Masters 6 – Doctoral Schools Attended (Post High) and training received:
InformationIntakeRevisionforDatabase.docx