JAMP Special Education
251 W. 2nd Street
Grand Chain, IL 62941
Phone: (618) 634-9800
Fax: (618) 634-9864

Student Input Information for CRT

Student's Legal Name:  
Birth Date:  
Address: City: Zip:
Parent's Name: Phone #: Cell #:
Foster Child: Yes No  
Foster/Guardian Name:  
Resident District:  
Home School:  
Serving District:  
Serving School:  
Student Beginning
Date for Service: 		 
Transfer Student: Yes No From Where:  
Grade in School: 01 02 03 04 05 06 07 08 09 10 11 12
13 (P1: EC & Pre-K year 1)
14 (P2: Pre-K years 2 & 3)
15 (KG: Kindergarten)
Ethnic Code: 11 Hispanic 12 Indian/Alaskan Native 13 Asian 14 Black
15 Hawaiian/Pacific Islander 16 White 17 Two or more races
Language: English or  
Gender: Male Female  
Completed By: Phone:
Email Address:  
By submitting this form an email will automatically be sent to secretary2@jampsped.org. If you are unsure if the submission of this form was successful please FAX to Tammy 618-634-9864 or email secretary2@jampsped.org.
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