Does Your Child Have Special Needs

Enter Child's name below:

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Enter Parent's name below:

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Parent's Email REQUIRED Please fill out this field. Please enter an email address.

Grade REQUIRED Please fill out this field. Please enter an integer (number).

Please click all that apply: ADD/ADHD Medical/Food Allergy Medical Condition/Other Special Services: IEP, Resource Room, In-class Support

Please provide an explanation of the above answers

Additional Family Information: Please explain

Is there anyone that may not transport your child home?

Are you a single parent? Yes No

Parent(s) deceased? Yes No

Parent's Seperated/divorced?* Yes No

Non-parental guardianship?* Yes No

Custody/visitations issues?* Yes No

Please provide any information or explanation on the above answers

* A copy of your court documents must be mailed to the parish office:

Director of Religious Education
St Matthew the Apostle Rectory
81 Seymour Avenue
Edison, NJ 08817