Region One Region One Coop Request for Assistance Step 1 of 2 50% Select Area of ChoiceRegion 1 (EHR, NCR, SWR)Distance Learning Program CLICK HERE TO FILL OUT THE DISTANCE LEARNING PROGRAM FORMStudent InformationStudent's Legal Name First Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920EthnicityGenderMaleFemaleSchool DistrictSchool of AttendanceSchool PhoneSchool Address Street Address City State Zip Student Grade LevelSAIS #Classroom TeacherParents/Guardians (click the + to add more than one)First NameLast Name Home LanguageHome Address Street Address City State Zip PhoneWork PhoneReferral SourceName First Last TitlePhoneEmail Specifics of ReferralReason for Referral* Hearing Evaluation Functional Vision Assessment (MUST attach ophthalmological information) Student transferring to district with Current IEP & Eligibility as VI student. Student transferring to district with Current IEP & Eligibility as HI student. Transferring from Preschool Transferring Current Services to Distant Learning Service *If the student is currently receiving special services, please list eligibility category. List any additional handicapping conditions. FIle Attachments * Attach current (within a year) hearing evaluation/audiogram or vision information, current IEP & Comprehensive Evaluation (if available). * If student has failed at least 2 school hearing screenings this school year, please attach results. Drop files here or Has the Special Education Director been notified?YesNoSpecial Education Director Name First Last Special Education Director Email Special Education Director PhonePhoneThis field is for validation purposes and should be left unchanged.