Special Education Registration Form

Page 1 of 1

1.	School:*

2.	Please describe where the bus should arrive to pick your group up. For example: front door, Door 20 in rear of school, color of door*

3.	Date of visit to Belwin:*
	mm/dd/yyyy

4.	Your name(s):*

5.	Phone:

6.	Email address:

7.	Total Number of Students (max 12):*

8.	Number of Staff:*

9.	Grade Levels or Ages (i.e. K-1 grades, 6-8 grades, Transition):*

10.	Classroom Description (such as ASD, DCD, OH, etc.):*

11.	Number of students using wheelchairs:*

12.	Number of students requiring bus harnesses for your group.*

	Please list your top 3 choices after checking the program descriptions to see what programming works for your group with regard to season, age, and endurance. I will try my best to honor your first choice!

13.	Choice 1:

14.	Choice 2:

15.	Choice 3:

16.	Special Considerations Please indicate if there are medical or mobility concerns, allergies (bee sting, food), or sensitivities.

17.	To help me prepare the lesson, are there students who are non-verbal in your classroom?*

18.	Endurance Level:* Choose one that best describes your groups ability to travel:

Done

Save

Cancel