2022-2023 Beacon Application

Please answer the following questions about the applicant. When this application is complete a Beacon case manager will contact you and set a meeting to discuss the applicant’s eligibility for the program.

Student's Name Student's Name First Last
Grade
Parent's Name Parent's Name First Last
Parent's Email
Has the applicant been screened for special education by a public school or private agency?

Has the applicant been screened for special education by a public school or private agency?
Yes No
If yes, please provide details.
Has the applicant been in any special needs or resource programs?

Has the applicant been in any special needs or resource programs? Yes No
If yes, please provide details.
Does the applicant have an IEP (individualized Education Plan) or 504 Plan?

Does the applicant have an IEP (individualized Education Plan) or 504 Plan? Yes No
If yes, please provide details.
Has the applicant been involved with early intervention services? (speech, developmental delays, focusing/attention issues)

Has the applicant been involved with early intervention services? (speech, developmental delays, focusing/attention issues) Yes No
If yes, please provide details.
Does the applicant receive behavioral counseling services on a regular basis?

Does the applicant receive behavioral counseling services on a regular basis?
Yes No
If yes, please explain.
Does the applicant currently receive any professional educational support outside of school? (private learning center, private tutoring, small group instruction, occupational therapy)

Does the applicant currently receive any professional educational support outside of school? (private learning center, private tutoring, small group instruction, occupational therapy) Yes No
If yes, please explain.
Does the applicant have any special medical needs?

Does the applicant have any special medical needs?
Yes No
If yes, please provide details.
Does the applicant take medication for any medical reason on a daily basis? (ADHD, Diabetes, Asthma, Allergies,etc.)

Does the applicant take medication for any medical reason on a daily basis? (ADHD, Diabetes, Asthma, Allergies,etc.)
Yes No
If yes, please list the medication below.
Why do you wish the applicant to participate in the BEACON program?
Is there any other information you believe we should know about the applicant?

Is there any other information you believe we should know about the applicant?
Yes No
If yes, provide details.
Parent's/Guardian's Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
Please click submit to continue to the Beacon Financial Agreement.