Student Demographic Info - Excent Tera

Please use this form to submit Student Demographic information for TIENET. Any questions can be directed to Jacqui Venier at extension 8625 or Shawna Dippman at extension 8620.

STUDENT INFORMATION

Start Date: MM/DD/YYYY

Last Name:

Full Legal First Name:

Middle Name/Initial:

Date of Birth:

Gender:

Race:

Primary Disability (if on a placement)

Resident District:

Operating District:

Attending School Building:

Grade:

Primary Manager:

Requestor (your name):

Choose one/enter date below Initial Evaluation In-state placement Out of state placement

Previous District:

Date of most recent IEP:

Date of most recent MET:

Transfer/New Enrollment Form, Medicaid Consent & Notice has been filed in CA60

Medicaid Consent Form sent to ISD

Special Transportation

Services/Time

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name

Parent/Guardian Address

Parent/Guardian Phone #

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