Madison City Schools
Child Count Verification Form
Complete this form each time records are sent to Central Office. Original copies must be attached.
 Transfer IEP
 Amended IEP (Addendum)  Annual IEP
 Initial Eligibility  Re-evaluation  Other _______________________________________
Student's Complete Legal Name ____________________________________
Grade_________
Exceptionality _________________ LRE___________________
School Code___________________ Case Manager____________________________
 Active
 Inactive (Check reason below and provide date and attach Notice of Intent)
 Graduated  Regular diploma  Certificate ___________date
 No longer eligible ___________date  Moved ____________date
 Reached maximum age
 Dropped out ___________date
 Not eligible _______________date
 Referred
School Codes
Columbia 0030
Heritage 0010
Horizon 0075
Madison
0085
Rainbow
0020
West Madison 0220
Mill Creek
0090
Discovery
Liberty
Bob Jones
James Clemens
0082
0083
0080
0095
Complete this section only during Child Count or upon special request. PLEASE check most current EDC
report.
Exceptionality ____________________
LRE ___________
Most recent date enrolled in Special Education (Consent for Services date) _________________
Referral date_______________________
Date of Initial IEP_____________________
Date of current IEP____________________ Re-evaluation date_____________________
Complete this section at the end of the year for students moving to a new school.
Student moving to _________________________
Special considerations____________________________________________________________________________
**Required**
Signature__________________________________________ Date____________________________________
8/1/13