Request for AT Team Contact - Mississippi Bend Area Education Agency

The mission of the Mississippi Bend Area Education Agency is to improve teaching and learning for all students through active partnerships and assertive leadership in a climate of mutual respect.

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* denotes required fields
STUDENT INFORMATION

Date Submitted:
Your Name: *
Position: *
School: *
District: *
E-mail: *
Phone Number: *
Student Name: *
Grade: *
Date of Birth: *	(mm/dd/yyyy)
Parent Name(s): *
Does Student Have an IEP?: *
If "Yes", Date:	(mm/dd/yyyy)
Does Student Have a 504 Plan?: *
If "Yes", Date:	(mm/dd/yyyy)

REQUEST DETAIL

Reason For Request: *
Is there a specific AT device that you are considering?: *
Do you anticipate increased access to core curriculum through use of AT?: *
Do you anticipate increased student achievement through use of AT?: *
Briefly describe the AT devices used by this student related to the current concern: *
Names/positions of team members who will work with this student during any AT device trials: *
Check all service currently received by the student:	Autism Resource Team Early Childhood Special Educator Educational Consultant Hearing - Audiologist Hearing - Itinerant Teacher Music Therapist Occupational Therapist (OT) Orientation and Mobility Specialist (OM) Physical Therapist (PT) Psychologist Speech-Language Pathologist (SLP) Traumatic Brain Injury Team Vision Teacher Work Study Coordinator Other:

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