E-mail:
District:	Choose One Arlington Britton-Hecla Castlewood Clark De Smet Deubrook Deuel Elkton Enemy Swim Estelline Florence Hamlin Henry Iroquois Lake Preston Oldham-Ramona-Rutland Rosholt Sioux Valley Summit Waubay Waverly Webster Willow Lake Wilmot
Student Name:
Grade:	Choose One K 1 2 3 4 5 6 7 8 9 10 11 12 12+
Disability:	Choose One Autism Cognitive Disability Multiple Disabilities Orthopedic Impairment Other
Intellectual Ability Score:
Developmental Age Estimate:
Are there attendance concerns?	Choose One Yes No Unknown

Why are you seeking enrollment for this student?

What supports have you tried for this student?

Describe the adult support needed for the student with their academics.

Describe any needs the student has with toileting, eating, and being independent as well as the adult support currently being provided.

Describe any behavior issues and the current supports you are providing for those behaviors.

Describe the student's strengths and needs in social skills.

Is this an alternate assessment student?	Choose One Yes No Unknown
Might this student graduate with a regular diploma?	Choose One Yes No Unknown
Might this student need services until age 21?	Choose One Yes No Unknown
Might this student return to a classroom in your district?	Choose One Yes No Unknown

Students who enter our program will not access general education curriculum and will work on modified curriculum. They will not graduate with a regular diploma and will likely not be taught skills to enter post secondary education including technical education. The decision to enroll changes the trajectory for students. Is your team in agreement with this placement and have you discussed these things with the parent? Choose One Yes No Unknown