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WCECC PreK New Student Enrollment Form
* Indicates required question
Email
*
Record my email address with my response
Student's FULL Name: First, Middle, Last
*
Do not use nicknames or initials - full legal name is required.
Your answer
Does this child have an IEP?
*
Do not use this form for Referrals - Do not use this form when moving from Speech IEP
YES - IEP SPEECH ONLY
NO IEP
YES - IEP w/ developmental services
Resident District - Where does child live?
*
Choose
Johnston City - Unit 1
Marion - Unit 2
Crab Orchard - Unit 3
Herrin - Unit 4
Carterville - Unit 5
Other
Student's Date of Birth
*
MM
/
DD
/
YYYY
Student's Gender
*
Choose
Male
Female
Enrollment Date
*
What is the first day this student attending YOUR school?
MM
/
DD
/
YYYY
Student's Ethnicity
*
Ethnicity/Race as recognized by ISBE reporting
Choose
White
Black
Hispanic
Asian
Hawaiian/ Pacific Islander
American Indian/ Alaskan Nat.
Two or More Races
SIS Number
*
Your answer
MEDICAID #
*
Your answer
Guardian's Name
*
Include First, Last Name
Your answer
Address
*
Include Street Address and City
Your answer
Phone
*
Include multiple phones if available - if no phone - please write no phone
Your answer
Serving School - Where will the child be attending?
*
Jefferson JC Regular PreK
Jefferson JC Blended PreK
Marion Adams Regular PreK
Marion Jefferson Regular PreK
Marion Jefferson Blended PreK
Marion Jefferson Early Childhood Self Contained
Crab Orchard Regular PreK
Herrin Northside Regular PreK
Herrin Northside Blended PreK
Herrin Northside Early Childhood Self Contained
Carterville TriC Regular PreK
Carterville TriC Blended PreK
Carterville Early Childhood Self Contained
Other:
Session Attended
*
AM
PM
DATE of Last Evaluation
MM
/
DD
/
YYYY
Date of Last IEP
MM
/
DD
/
YYYY
Case Manager
*
Your answer
Students Primary Disability
*
Your answer
Students Secondary Disability
Your answer
Percentage of Time General ED
*
Your answer
Percentage of Time Special Ed
*
Your answer
Previous School Attended
Your answer
Brechts Data Base
Your answer
Does the Student Receive Related Services please describe
*
Your answer
Person completing form - enter your email address
*
EMAIL
Your answer
A copy of your responses will be emailed to .
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