Eastern Oregon Regional Inclusive Services Referral
*Only to be completed by Case Managers*
We (the school district) are requesting the assistance of Eastern Oregon Regional Inclusive Services with the following:
Please check all that apply:
*
Required
Blind / Visually Impaired
Deaf / Blind
Deaf / Hard of Hearing
Traumatic Brain Injury
IFSP / IEP Information
Does student have a current IFSP / IEP?
Yes
No
If yes, please attach the following required documents:
Service Summary Page
Eligibility Statement (if available)
Current IFSP / IEP Date:
Case Manager's Name:
*
Required
Case Manager's Email:
*
Required
Student Information
Student's First Name:
*
Required
Student's Middle Initial:
Student's Last Name:
*
Required
Student's Date of Birth:
*
Required
Student's Gender:
*
Required
Student's SSID# (not District ID#)
*
Required
School District Information
School District:
*
Required
School:
*
Required
Grade:
*
Required
If you have any questions, please contact the following people:
Tonya Smith
Director of Regional Inclusive Services
541-966-3145
tonya.smith@imesd.k12.or.us
Patty Jo Lathrop
Administrative Assistant
541-966-3194
pattyjo.lathrop@imesd.k12.or.us
Submit
