Proctor - New Student Form

Proctor - New Student Form

Proctor Staff only - Use this to report new students, returning students or "new to you" students.

Questions marked with an * are required

Case Manager Name *
 
Your email (if you want a copy of the data submitted sent to you via email):
 
Student First and Last Name *
 
State ID/MARSS #
 
Grade * 













 
Birthday
 (mm/dd/yyyy)
 
Gender
 Male 
 
Federal Ethnicity (please mark one). Is the student's ethnicity Hispanic or Latino? (Cuban, Mexican, Puerto Rican, South or Central American or other spanish culture or orgin, regardless of race).

 
Race - Check ALL that apply
 Native American / Alaskan Native 


/ African American
 
Primary Language other than English *
Yes
No
 

Residency is determined on where the legal guardian lives regardless of where the student lives.

Enter parent or legal guardian information here.

Parent's Name
 
Parent's Address
 
Parent's City, State, Zip
 
Parent's Primary Phone
 
Relationship to Learner 

 
Have parental rights been terminated? * 

 
Is the student a Ward of the State? * 

 

If the student lives with someone other than the legal guardian, please answer the next set of questions (foster home, grandparent, friend, etc).

Primary Name
 
Primary Relationship 
 N/A 
 
Primary Address
 
Primary City, State, Zip
 
Resident District (resident district is determined by where the legal guardian lives not necessarily where the student lives). *
 
State Aid Category * 

01 - Open Enrollment


 16 - Shared Time Aid (Resident District)
 17 - Shared Time Aid (Serving District)
28 - Nonpublic placed IEP/IFSP/IIIP or care & treatment

 
Transportation District *
 
Transportation Category * 


 
Attending School * 
 Bayview Elementary
 Jedlicka Middle School
 Mesabi Preschool Academy
 NERCC
 Pike Lake Elementary
 Proctor Early Childhood Center
 Proctor Essential Learning School
 Proctor High School
 
Adopting Existing IEP * 

 
Enrollment Start Date
 (mm/dd/yyyy)
 
Is this a new IEP/IFSP/IIIP? * 

 
Service Start Date *
 (mm/dd/yyyy)
 
Evaluation Status (SEES) * 
1 - Not evaluated, non-disabled, no IEP/IFSP regular education only2 - Shared-Time K-12 – Evaluated, EC – Evaluated
 3 - Evaluated – requires services but not yet in a program
Evaluated – receiving special education services (IEP/IFSP)
 5 - Evaluated – qualifies for services, parent refused
Evaluated – receiving services in district and receiving services through a public agency (IIIP)
 
Instructional Setting - Ages 6-21 *









 33 - EC or K Program (max 10 hrs/wk in this setting) 





 
Instructional Setting - Ages B-2 * 






 
Instructional Setting - Ages 3-5 *









 
Primary Disability * 













 

Early Childhood Only (B-K)

Community Program of Enrollment
  Stepping Stones - Proctor EC Center
  Stepping Stones - Pike Lake
  School Readiness - Proctor EC Center
  School Readiness - Pike Lake
  Little Rails Preschool - Bay View
  Mesabi Preschool Academy
  Child Care Connections - Proctor
  Child Care Connections - Pike Lake
  N/A
 

ECSE Class Placement? 
3-5 ECSE Non District
3-5 Non District Speech
3-5 District ECSE
B-3 Home Visits
B-3 Child Care Center
B-3 Home Speech
N/A

 
Evaluation Start Date
 (mm/dd/yyyy)
 
Evaluation End Date
 (mm/dd/yyyy)
 
Total Evaluation Hours
 
Comments
 
 

 

 



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