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.
Enlarged City School District of Middletown, New York
New Entrant Registration-Disability Questionnaire
Student: D.O.B.: Date:
Grade: Home School (official use only):
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:
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 ?
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