Free Special Education Admission Form Template
Special Education Admission Form
Please fill out this form completely to apply for admission to our special education program.
Applicant Information
Name
Date of Birth
Age
Gender
Nationality
Parent/Guardian Information
Name
Relationship to Applicant
Contact Number
Home Address
Educational Background
Previous School Name
Grade Completed
Intended Enrollment Date
Special Educational Needs
Diagnosis or Learning Disabilities
IEP (Individualized Education Program) or Support Plan
If yes, please provide details:
Therapies and Services
Does the applicant currently receive any therapies or support services (e.g., speech, occupational, physical therapy)?
If yes, please specify:
Medical Information
Do you have any medical conditions we should be aware of
If yes, please provide details
Emergency Contact
Name
Relationship to Applicant
Contact Number
Declaration
I hereby declare that the information provided in this form is true and correct to the best of my knowledge.
Applicant
Name:
Date:
Parent/Guardian
Name:
Date:
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