Hazleton Area School District Early Intervention Referral

Student Referral Record
Child First Name:
Child Last Name:
Child DOB:
Address
Gender
Why are you referring your child?
Have you made previous referral?
What is your child's ethnicity?
What is your child's race?
What is your family's preferred language?
Does your child have Medical Assistance?
MA Number:
With whom does your child reside?
What county does your child live in?
What school district does your child live in?
What year will your child be eligible to enter kindergarten?
How did you hear of the program?
Does your child attend preschool or daycare?
Guardian 1 Information:
First Name:
Last Name:
Address 1:
Address 2:
City:
State:
ZIP:
Contact Number:
Email Address:
What is the relationship of the legal guardian to the child?
Do you have educational rights?
Guardian 2 Information:
First Name:
Last Name:
Address 1:
Address 2:
City:
State:
ZIP:
Contact Number:
Email Address:
What is the relationship of the legal guardian to the child?
Do you have educational rights?
Adopted Information:
Is Child Adopted?
Is Foster Parent the Legal Guardian?
Additional Information:
Is there any additional information we need to be aware of?
Name of Person Submitting Form:
First Name:
Last Name:
Address 1:
Address 2:
City:
State:
ZIP:
Contact Number:
Email Address:
Please check all areas of concern that apply to your child.  This information will give us a better overall understanding of your child.
  • Cognitive (How your child learns and uses information)
  • Speech and Language
  • Behavior
  • Social
  • Sensory