Child Services Survey

Child’s Name _________________________________________________ Grade________________

Address_________________________________________________________________________________

Phone Number____________________________________________________________________________

*** Please check all that apply

________ My child has not received special services

________ My child received special services from our previous school

________ My child currently has an IEP from previous school

(Please attach a copy of the IEP to this page)

_____________________________________________ _____________________________

Parent’s Signature Date

*If you do not have a copy of the IEP please fill out the information below

School Name_____________________________________________________________________________

School Address____________________________________________________________________________

______________________________________ ______________________________ __________

City State Zip

School Phone Number ( ) ________________________________ Fax ( )___________________________

Contact Person at School______________________________________________________________________