2015-2016 STUDENT ENROLLMENT FORM
**Acceptance upon Final Review of Records by BOCES**
First Name:
Birth Date:
Race:
Last Name:
MI:
Gender:
American Indian
Grade: (As of Sept 2015)
African American
Hispanic/Latino:
Asian
Pacific Islander
School District:
District Building:
District Student ID#:
District of Residence:
White
Mailing Address:
City:
State:
Zip:
Parent/Guardian Name 1:
Address:
Relationship:
City:
State:
Home Phone:
Zip:
Work Phone:
Lives with:
Yes
No
Yes
No
Cell Phone:
Parent/Guardian Name 2:
Address:
Relationship:
City:
State:
Home Phone:
Zip:
Lives with:
Work Phone:
Cell Phone:
** Program/Course Enrollment is Based on a First Come – First Serve Basis **
ADD/CONTINUE Student:
Is this an Additional Request for Service?
Yes
No
If Yes, please process an ARFS form PRIOR to enrollment.
BOCES Site:
Prog
ram:
A
M
P
M
Full Day
CTE
Cour
se:
A
M
P
M
Full Day
Tentative Start Date:
Check ONE in each of the following categories:
Lunch:
Testing:
US Enroll Date:
Home Language:
Year Entered Grade 9 (Sept):
Disability:
Student has a Behavioral Intervention Plan:
Medicaid Eligible:
ELL Years:
Yes
Yes
No
If classified, please attach IEP
No
CIN #:
If yes, please attach BIP to Enrollment Form
Agency:
Med Service Coordinator:
Phone:
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Not Free
NYS Assessment
PROVIDE RELATED SERVICES:
Effective Date:
Location of Service:
2015 -16 School Year is a Triennial Year for this student.
Nursing:
Skilled Nurse
x6
Student Physical (Grades K, 1, 3, 7 & 10 – Special Ed also grade 5)
Parental approval is on file at the district for Triennial Testing.
and/or
MIN-I
MIN-G
x6
Listed below are the ONLY Related Services offered by BOCES – they are NOT INCLUDED in program tuition & generate additional costs.
For clarification, contact Sue Tiffany @ 763-3318.
Check all that apply and list % - ONLY Possible choices: 50%, 100%
Aide:
%
Monitor:
Home Teaching:
x 6 for
%
Interpreter:
%
Scribe: % TBD by BOCES
wks
MIN-I
and/or
x6
MIN-G
x6
x6
x6
MIN-I
and/or
MIN-I
MIN-I
and/or
x6
x6
x6
MIN-G
and/or
Occupational Therapy
Physical Therapy
x6
x6
MIN-I
and/or
MIN-I
x6
x6
MIN-G
and/or
Adaptive PE (In addition to Program)
x6
MIN-I
and/or
x6
MIN-G
Speech (Disabled)
Hearing Impaired
x6
x6
MIN-I
and/or
and/or
x6
x6
MIN-G
MIN-I
Visually Impaired
x6
MIN-I
and/or
x6
MIN-G
Counseling (In addition to Program)
x6
Consultant Special Education Teacher:
Student Based
Family Training/Counseling
School Personnel Support
MIN-G
MIN-G
** Please Attach Prescriptions**
MIN-G
MIN-G
Individual Evaluation – Please describe:
Purpose:
CHANGE Student Placement:
Desired Effective Date:
FROM: (Current BOCES Site/Program/Course):
AM
PM
Full Day
AM
PM
Full Day
TO: (New BOCES Site/Program/Course):
DROP Student:
If student is enrolled in multiple BOCES programs, please specify ALL program(s)/service(s) you would like discontinued.
Program/Course/Service(s):
Desired Effective Date:
Please Note: Drops are processed on the date received in the BOCES Student Data Center and CANNOT be backdated.
Reason for Dropping:
This form must have a contact name in the signature field and both page 1 & 2 must be submitted to be processed.
Date:
Signature:
(ADMIN/CSE/CNSLR)
SEND PAPERWORK TO BOCES STUDENT DATA CENTER: Fax: 607-763-3614 - email: sdc@btboces.org - Mail: Ed Center, #20
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