Items denoted with a red asterisk * are required.
 * Case Manager
 
 * Student First Name
 
 * Student Middle Name
 
 * Student Last Name
 
 * Social Security # or Medicaid #
 

This should be provided when this form is completed.
 * Date of Birth
 
 * Proof of Age:
 





Required for NCWISE
 * Gender
 
 * Does the student identify as Hispanic/Latino?
 
 * Race
 






Make sure to choose "ALL" races that apply.
 * Observer Defined Race/Ethnicity:
 



If the parent does not specify the race, you must chose "yes".
 * Address
 
Address 1
Address 2
City
State
Zip Code
 * Phone Number
 
 * LEP Student
 
 * Student Lives With:
 
 * Parent/Guardian Name
 
Is this student in a:
 
 * Referral Received by School Date
 

This date will begin the 90 day timeline!
List name of Preschool/Daycare/Private School or list home schooled
 

If student is enrolled in one of our PK classes at Dudley Shoals, Valmead or Whitnel, then list that school here.