Q. Assisted Evacuation Plans for Students with Special Needs Form

Name of Child _________________________________________________________________

Building _____________________________________________________________________

Teacher and Room _____________________________________________________________

Reason child needs assistance ____________________________________________________

Assistance to be given __________________________________________________________

Person responsible _____________________________________________________________

Alternate person responsible _____________________________________________________

Special arrangements needed at assembly area ________________________________________

Other pertinent information ______________________________________________________

Attach copy of student’s class schedule and out‑of‑classroom services.

__________________________________________________________

Signature of person who prepared plan Date

Copies on file:

Circulate information to all special area or class teachers. Copy of plan should be kept with class attendance roster.

Update plan annually by October 1 (and document this review).