Transition Program
Bemidji State University
Guidance Counselor Form

Transitioning Program Applicant : ___________________________________________

Date of Birth___________

High School Attending_______________________________ Grade Level___________

Instructions:   The above named student is interested in participating in the Transitioning Program at Bemidji State University .   The Transitioning Program is an educational program designed to prepare and help motivate high school students who have a documented disability and the potential for success in post-secondary education.   The week long program at Bemidji State University will be followed by extensive follow-up through the rest of the student's high school career.

The information requested will assist the processing of this application and provide information used by the Transitioning Program for student performance reports and the measurement of program performance objectives.   An authorization to release education information is in the student's application packet (p.4). Please make a copy of the signed release for your records.

Name and contact information of student's parent/s or guardian_______________________

________________________________________________________________________

Student's Transcripts and other information including:

____attendance records
____ grades
____ courses taken
____ class rank  
____ Minnesota graduation standards   
____ standardized test scores  
____ grade point averages
____ IEP (Individualized Education Plans) and IEP reviews       
____ diagnostic data such as psychological or learning skills assessments
____ conduct or discipline records
____ 5x8 medical information card completed and signed by student's parents and submitted to counselor