To use these forms, please download to fill out. Thank you!

• Form 30 - School District Requests 
• NWRESD Regional Inclusive Services Referral Form
• Authorization of information 

• ASL interpreter request form
• Form 30 - School District Requests 
• Important: requests not accompanied by a signed form 30 will not be fulfilled. Please email completed form 30 to ASLinterpreterrequests@nwresd.k12.or.us.

To use these forms, please download to fill out. Thank you!

• District request for audiological evaluation

Important: Prior to initiating the regional student referral for Blind/Visually Impaired services please complete the authorization to use and/or disclose educational and protected health information for an ophthalmologist or optometrist. To make a referral, please complete the Regional Inclusive Services Referral Form.

Contact Stephanie Karpouzes or Amy Frame with questions. 

To use these forms, please download to fill out. Thank you!

• American printing house consent 
  • English 
  • Spanish
    
    
• Authorization of Information (Protected health information)
  • Authorization to use and/or disclose educational and protected health information 
  • Kaiser authorization to use and/or disclose patient health information - English
  • Kaiser authorization to use/or disclose patient health information - Spanish
  • NWRESD OHSU use and disclosure protected health information authorization - English
  • OHSU use and disclosure protected health information authorization - Spanish

• EI/ECSE vision screening tool

• Orientation and Mobility (O&M) Emergency contacts 
  • English
  • Spanish
    
    
• Orientation and Mobility (O&M) Permission to Transport   
  •  English
  •  Spanish
    
    
• Report of eye exam