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Birth Date
Month
Day
Year
Teacher Name
School Name
District
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tsaL
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American Indian
or Alaska Native
African American or
Black, Not Hispanic
Asian
Pacific Islander
Hispanic or Latino
White, Not Hispanic
Multiethnic
Other
January
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Grade
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Gender
Ethnicity
Home
Language
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IEP
504
LEP/
ELL
R L MA SC SS InV
CATEGORY
STUDENT’S NAME
ID Number
Special Codes
A B C D E F G H I
J K L M N O P
Testing
Accommodations
STUDENT INFORMATION FORM
5493800
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Published by CTB/McGraw-Hill LLC, 20 Ryan Ranch Road, Monterey, California 93940-5703.
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