VISION Home and Community Program

Enrollment Form

2006-2007

Learner’s Legal Name: _________________ ______________ _________________

(First) (Middle) (Last)

Physical Address: _________________________________________________________

Street Number

_____________________ _______ _____________

City State Zip

Mailing Address: _________________________________________________________

Street or P.O. Box Number

______________________ _______ _____________

City State Zip

Home Phone: __________________________ E-Mail: _________________________

Father’s Name: ___________________________ Work/Cell Phone: ________________

Mother’s Name: ___________________________ Work/Cell Phone:_________________

Emergency contact:

Name: _________________________ Relationship to Learner: _________________

Phone: _____________________

SURFACE CREEK VISION RELATIONSHIP INFORMATION

Level of participation: ____ Full-time (360+ hours/semester)

____ Part-time (90+ hours/semester)

Resource Consultant: ___________________________________

Meeting: _________Monthly __________ Semi-Weekly _________Weekly

2006 - 2007 Grade Level: _______________

(Must match Basic Skills Assessment Form: RC’s initials __________)

Colorado State Demographic Information

The following information is required by the State of Colorado for all students enrolled

in the public school system. Therefore, Surface Creek Vision HCP will be providing this information to the Delta County School District and the State of Colorado.

Date of Birth (MM/DD/YY): ________________

SSN:________ - ________ - _________

Gender: Male: _______ Female:_______

Ethnic Background:

q Caucasian

q Asian

q Hispanic

q African American

q American Indian

Does the Learner have a current IEP (Individualized Education Plan) on file with the

Delta County School District? Yes: ______ No: ______

If yes, from what school? __________________________

Does the Learner have a physical handicap? Yes: ______ No: ______

If yes, please describe: ______________________________________________

ENROLLMENT HISTORY

Where has the Learner been educated since September 1, 2003?

Please list separately each school attended since 2003.

Name/Location of School

Public/Private/Home School?

From

To

*Please remember, Vision is not considered “homeschooling” by the State. If the Learner was enrolled in any Vision program, it must be listed as a public school. If the Learner was schooling at home but not enrolled in Vision, “Homeschool” can be listed.