2016-2017 Community Residential Center Roster/Withdrawal Form CRCF-2

2016-2017 Community Residential Center Roster/Withdrawal Form CRCF-2

Roster must be signed and mailed; postmark must be within sixty (60) calendar days of enrollment in the CRC.

Last day for additional Roster submission: May 15, 2017.

Local Education Agency: LEA #: District Name: Select From Drop DownNortheastSoutheastNorth CentralSandhillsPiedmont-TriadSouthwestNorthwestWestern

Date: Community Residential Center:

**ESY services for Summer 2016 must be documented in the IEP; attach a copy of the DEC4 page noting the child’s ESY eligibility.

Child’s
NC Student ID
(PowerSchool #) / Child’s Last Name / Child’s First Name / Date of
Birth / Ethnicity / Gender / Disability
Based Upon CRCF-1 Information / Date of
Enrollment for Current School Year / Withdrawals / **ESY Enrollment Dates
(if applicable)
Month/ Year
Date / Code*
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1 - Transferred to LEAW2 - Transferred to private schoolW3 - Transferred to another CRCW4 - Moved out of school districtW5 - Moved out of stateW6 - Withdrawn from schoolW7 - Exited/no longer eligible for servicesW8 - DeceasedW9 - Describe below
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE
AI/AL - American Indian or Alaskan NativeAS - AsianB/AA - Black or African AmericanHI/PI - Hawaiian Native or Pacific IslanderIsH - Is Hispanic or LatinoT - Two or MoreW - White / MF / AU - Autism Spectrum DisorderDB - Deaf-blindnessDF - DeafnessDD - Developmental DelayED - Emotional DisabilityHI - Hearing ImpairmentIDMI - Intelectual Disability - MildIDMO - Intelectual Disability - ModerateIDSE - Intellectual Disability - SevereLD - Specific Learning DisabilityMU - Multiple DisabilitiesOHI - Other Health ImpairementOI - Orthodpedic ImpairementSLI - Speech or Language ImpairementTBI - Traumatic Brain InjuryVI - Visual Impairement, including Blindness / W1W2W3W4W5W6W7W8W9 - DESCRIBE

W-9 (provide description here)

Check if newly enrolled child is replacing a withdrawn child

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Signature of Exceptional Children Program Director Date

DPI Use Only Postmarked Date ______Processor ______MOF______Entered Date______FFM#______

NOTES:______

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