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District 26 Assistive Technology Background Information Form
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* Indicates required question
Email
*
Your email
Student Name
*
Your answer
Date of Birth
*
Your answer
Grade/Room#:
Your answer
Date of Referral:
*
MM
/
DD
/
YYYY
School
*
Choose
Euclid
Indian Grove
Prairie Trails
River Trails
Referred by (name & title):
*
Your answer
Disability if Already Eligible: (Check all that apply)
Autism
Cognitive Impairment
Learning Disability
Emotional Disability
Deaf/Blind
Developmental Delay
ADHD
Hearing Impairment
Speech/Language
Multiple Disability
Vision Impairment
Orthopedic Impairment
OHI
504
Traumatic Brain Injury
List Special Education Services the child is receiving if already eligible:
Your answer
This student needs support to:
Support Communication (Student is nonverbal or unintelligible)
Access School Curriculum (Reading, Writing, Math, Executive Functioning, etc)
Any Additional Comments:
Your answer
Submit
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