Special Education Student Inquiry Form

Wayne RESA Online Student Referral form

If the child is not yet eligible for kindergarten, please use the state’s website to submit a request for Early On, Build Up, or Help Me Grow

Student Information

Student First Name

Student Middle Name

Student Last Name

Student's date of birth (MM/DD/YYYY)

Student Address + District

Address Line 1

Address Line 2

City

Zip Code

We cannot use P.O. Box numbers

Student District of Residence or School District

Student's Gender

Male

Female

Ethnicity (click all that apply)

Other (please specify)

Current School Attending / or Plan to Attend

Student Developmental Concerns

Please give a detailed description of the concern/reason(s) for request

Student communication

Student Behavior / Social Interaction

Student self-care

Parent/Guardian Information

Parent or Guardian First Name

Parent or Guardian Last Name

Parent / Guardian Phone

Parent / Guardian Alt. Phone

Text Messages (SMS) available?

Yes

Does the parent or guardian need an interpreter?

Yes

Language?

Guardianship

Birth parent

Adoptive parent

Foster parent

Legal guardian

Other

Other (please specify)

Same address as student?

Yes

Who is the student living with?

Who is helping parent complete this request?

Your relationship to the student

Other (please specify)

I am parent or legal guardian

Yes

Name & Agency

Agency Phone

Agency Fax

Agency Email

Additional Information

Do you have additional comments or questions?

For questions call (734) 334-1393. This form is intended for children attending Wayne County schools or living in Wayne County ONLY.

You will receive an email confirmation within three business days from [email protected]