Free Indiana Department of Health Clients Approval Form - Indiana

APPLICATION AND APPROVAL FOR ADMISSION
State Form 52397 (9-05)

INDIANA STATE DEPARTMENT OF HEALTH Silvercrest Children's Development Center

Per IC 16-33-3-8 INSTRUCTIONS: 1. This application form must be completed, signed and dated by the parent or guardian prior to submission to the Department of Education. 2. The approval must be signed by the proper Department of Education authorities prior to any child's referral to Silvercrest Children's Development Center.

SECTION I (to be completed by parent or guardian and local school corporation)

Child's name: _________________________________Date of Birth: ___________________ Home address: _____________________________Home phone number:________________ Name of parent(s) or guardian(s):_________________________________________________ Relationship to child: __________________________________________________________ Name of local school corporation: ________________________________________________ Address of local school corporation: ______________________________________________ Name of school: ______________________________________________________________ Special education cooperative (if applicable): Name: ______________________________________________________________________ Address:_____________________________________________________________________ Telephone number: ____________________________________________________________ Name and title of school contact person: ___________________________________________ Telephone number of school contact:______________________________________________ Provide written confirmation that the following conditions have been properly executed as provided for by IC 16-33-3-8: 1) The child being considered for admission to Silvercrest Development Center is a resident of the State of Indiana. 2) The child is now and will be less than 22 years of age at time of admittance.

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3) The child has at least two major disabling conditions. List the major disabling conditions:____________________________________________________________ (provide specific supporting documentation for each condition). ____________________________________ Parent or guardian _____________________________________ School representative providing information

SECTION II (to be completed by the school corporation) Provide written documentation that the following have been properly executed: 1) Annual Case Review 2) Individual Education Plan developed as a result of the Annual Case Review. Attach copies of all professional evaluations that have been conducted with the child to be considered for admission. I certify that the documentation provided is true, accurate and complete: ___________________________________________ School representative providing documentation Printed name:________________________________ Position:____________________________________

SECTION III (to be completed by State Department of Education, Division of Exceptional Learners) I certify that the referral of ___________________ has met the statutory requirements for consideration of admissions to Silvercrest Children's Development Center. In addition, it is the recommendation of the Indiana Department of Education that Silvercrest Children's Development Center is the institution best suited to serve the needs of ___________________ _________________________ as identified through the appropriate case conference meeting.

___________________________________ _____________________ Robert A. Marra (or his designee) Date Associate Superintendent, Division of Exceptional Learners Indiana Department of Education

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