Parent Report of Medical Disability or Diagnosis

Parent Report of Medical Disability/Diagnosis
The Glen Rose School District has a duty to identify, locate, refer and evaluate all students within this jurisdiction that may have a disability, and because of that disability require special services. Regardless of their abilities, if your child has a medical diagnosis or disability that may require special education services or accommodations through a Section 504 Plan, please provide this information to the school principal by contacting them directly or completing this form. This is an effort by the school district to provide a free appropriate public education and assure that every student has access to equitable educational opportunities to be successful in our district and to fulfill their potential.
Student Name *
School *

Glen Rose Kindergarten Glen Rose Elementary Glen Rose Middle Glen Rose High
Grade *
My child has a medical disability or diagnosis. *

No Yes
My child has a medical disability or diagnosis of:

ADHD (primarily inattentive, primarily impulsive/hyperactive, or both/combined) visual impairment hearing impairment diabetes autism arthritis asthma dyslexia Other
My child has an allergy/allergies

No Yes (mild - not life threatening) Yes (significant - life threatening) Type option 4 Other
The best way to contact me during the day is (phone or email address) *
I give my permission for the Glen Rose School District to contact my child's previous school(s) regarding special education and/or Section 504 records. I give my permission for my child's previous school(s) to share pertinent information and records with the Glen Rose School District for the purpose of appropriate placement and educational programming.
Parent/Guardian Name
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
DISTRICT USE ONLY
Date

Month Day Year
Date
Reviewed by
Date

Month Day Year
Date
Parent contacted by
Should be Empty:

Parent Report of Medical Disability/Diagnosis