Exceptional Children's Department Information Request Form
The Exceptional Childrens' Department of Rowan-Salisbury Schools looks forward to assisting you. Please provide the information requested below. Someone from our department will get back to you as soon as possible.
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Reason for Request
*
Please Select
Private School/Home School Student Referral
Concerns related to a student's current IEP
Concerns about my 3 or 4 year old student
Other
Student Last Name
*
Student First Name
*
Student Middle Name
*
Student Date of Birth
*
-
Month
-
Day
Year
Date
County and State of Birth
*
Student Address
*
Student Race (mark all that apply)
*
Black
White
Native Hawaiian or Other Pacific Islander
Asian
American Indian or Alaska Native
Student Ethnicity
*
Hispanic
Not Hispanic
Primary Language
*
Current School
*
Current Grade
*
Current Teacher
*
Mother's Name
*
Mother's phone number
*
Mother's email
*
Father's name
*
Father's Phone Number
*
Father's Email
*
Details of Request
Briefly provide information concerning your request.
*
Submit
Should be Empty: