Fillable TRANSITION REFERRAL Early Part C Exit

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TRANSITION REFERRAL Early Part C Exit

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Country of origin: US
File type: PDF

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SCDHHS/IDEA PART C/24AUG20/ALL PREVIOUS VERSIONS ARE VOID
TRANSITION REFERRAL AND LATE TRANSITION ALERT FORM
TRANSITION REFERRAL
New
Update
SECTION 1: DATE TRANSTION REFERRAL/CONFERENCE/EXIT FROM IDEA PART C
Transition Referral Date:
Transition Conference Due Date:
Date Referred to IDEA/Part C:
Late Referral
Early Part C Exit
SECTION 2: CHILD AND PARENT INFORMATION
Name of Child:
DOB:
BRIDGES ID:
Parent Name:
Address:
City:
State:
Zip Code:
Primary Phone Contact:
E-Mail Address:
SECTION 3: PRESCHOOL SERVICE PROVIDER: LEA HEAD START CHILD CARE
Name of LEA Preschool Coordinator or Contact for Different Placement:
Name of School District or Program:
Address:
City:
Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
SECTION 4: INTAKE COORDINATOR OR SERVICE COORDINATOR INFORMATION
Intake Coordinator Service Coordinator Name:
Agency:
Phone Number:
Fax Number:
E-Mail Address:
SCDHHS/IDEA PART C/24AUG20/ALL PREVIOUS VERSIONS ARE VOID
TRANSITION REFERRAL AND LATE TRANSITION ALERT FORM
SECTION 5: CONSENTS AND SIGNATURES
5A. Parent agrees to receive preschool services through the LEA:
NO
YES
5B. Parent agrees to take part in the Transition Conference:
NO
YES
5C. Consent obtained for information sharing with LEA or other
placement:
NO
YES
If yes:
consent and documents attached
consent and documents to be sent at a later date
Comments:
SIGNATURES REQUIRED IF 5A OR 5B ARE ANSWERED ‘NO.’
Parent Signature
Date
Intake/Service Coordinator Signature
Date
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TRANSITION REFERRAL Early Part C Exit

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Completed 25 May 2022

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