Disability Questionnaire Form

  • For accessiblity, below is an HTML representation of the document Disability Questionnaire form; please do not complete this version.  You must print this form to be able to submit it to our registration office. For the printable version click on the link below.

    Printable version of Disability Questionnaire form available here.

    Enlarged City School District of Middletown, New York

    New Entrant Registration-Disability Questionnaire

    Student:  D.O.B.:  Date:

    Grade:  Home School (official use only):

    Parents/Legal Guardian:


    Phone: Cell:


    Has this student been identified by the Committee on Special Education as a student with a disability?

    Yes □  No □

    If no, is this student suspected of having a disability? Yes □  No □                 

    Is this student in a Day Treatment or Residential Facility? Yes □  No □                   

    If yes, where?

    Are there other children in the household under the age of 21 who are disabled or are suspected of having disability?

    Yes □  No □

    If yes, please complete the following information:

    1. Name:                         
    2. Sex:        
    3. D.O.B:                    
    4. School:                      
    5. Grade:       
    6. Classification:

    Compensatory Education/Supplemental Instruction

    Has this student ever attended Middletown Schools? Yes □  No □        Dates:                                                                                                                     

    Please indicated if this student is receiving extra help in:                                                                                                                                                                        

    • Reading: Yes □  No □  
    • Math: Yes □  No □     
    • Writing: Yes □  No □   
    • Speech: Yes □  No □          
    • Other:                                                                                                                                                                   

    Do you feel this student needs additional help? Yes □  No □                       

    If yes, reason:

    This information will be kept confidential and will be forwarded directly to the Special Services Department

    Revised 11/9/16