Name of Last School Attended            _____________________________________________

    School Address                                   _____________________________________________________________

                                                                Street Address                                        City                    State      Zip Code

    School Phone Number                        _____________________________________________________

    School Fax Number                            _____________________________________________

    Student (s) Name                                _______________________________ DOB __________Grade ____

                                                                _______________________________ DOB __________Grade ____

                                                                _______________________________ DOB __________Grade ____ 


     The above named student(s) have been registered at Hickory Center Elementary.  We would appreciate receiving the following information:

     _____  EDUCATIONAL RECORDS- Include levels, progress reports, standard tests, scores, educational evaluations, most recent grade card

    _____  MEDICAL RECORDS- Include physical and all health and immunization records.

    _____  STUDENT SERVICE INFORMATION- Include special education records, as well as all psychological, psychiatric, and planning and placement team recommendations.

    _____  RACE/ETHNICITY Reporting Form


    _____  ENGLISH LANGUAGE LEARNER (ELL) RECORDS- Evaluations, scores, levels,

                progress reports

    Please deliver, mail, or fax completed information to the school that your child will be attending.