Early On / Special Education Child and Student Education Referral Form

WRESA Online Referral Form

Child / Student Referral Information

Is child under the age of three and being referred to Early On?

Yes

If yes, please STOP and click here to complete the State of Michigan Early On Form instead

Referral to

Build Up (3-4 yrs)

Child Find (K and up)

Child/Student Information

First Name

Middle Name

Last Name

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

Child / Student Address + District

Address Line 1

Address Line 2

City

Zip Code

We cannot use P.O. Box numbers

Child / Student District of Residence or School District

Child's Gender

Male

Female

Ethnicity (click all that apply)

Other (please specify)

Birth Details

Multiple birth?

Yes

How many?

Was the child premature?

Yes

How many weeks?

Does the child attend daycare, preschool, or school?

Yes

Where?

Child / Student Developmental Concerns

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

Child / Student communication

Child / Student social interaction

Child / Student movement and exploration

Child / Student self-care

Parent / Guardian Information

Does the parent or guardian need an interpreter?

Yes

Language?

Guardianship

Birth parent

Adoptive parent

Foster parent

Legal guardian

Other

Other (please specify)

First Name

Middle Name

Last Name

Phone

Alternative phone

Text Messages (SMS) available?

Yes

Parent Address Information

Same address as child?

Yes

Who is child living with?

Who is helping parent complete this request?

Your relationship to the child

Other (please specify)

I am parent or legal guardian

Yes

Name & Agency

Name & Agency Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Agency Phone

Fax

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 BuildUp@resa.net