1. Important Highlights for the Completion of DD Form 2792-1 “Special Education/Early Intervention Summary” NAVAL MEDICAL CENTER PORTSMOUTH EFMP OFFICE DD Form 2792 must be completed for all EFMP enrollees. DD Form 2792-1 is required if child is: 3 – 18 years of age 19 – 21 if still enrolled in school systems (typically a special needs student) < 3 if eligible for Early Intervention services

2. For EFM’s birth to age three, please check “YES” or “NO” in section 5. If the EFM’s age is up to age three and no early intervention services are received and the child does not have an Individualized Family Services Plan (IFSP) OR if your EFM is homeschooled, then only Page 2 will need to be completed and signed by the sponsor or spouse. DD Form 2792-1 Page 2 Family completes this page

3. For all other school-aged EFM’s, the sponsor (or spouse) will need to complete Page 2, sign the bottom of Page 2, AND the EFM’s school official will need to complete and sign Page 3. DD Form 2792-1 Page 2 EFMP Coordinator must complete this section Family completes this page

4. The sponsor or spouse must sign and date here to authorize the release of the EFM’s information. Upon completion of Page 3, the school official must complete all of section 8 and sign and date the bottom of Page 3. DD Form 2792-1 Page 3 Family completes this section School or Early Intervention complete this section

5. Additional Information If school annotates that there is a 504, Individualized Education Plan (IEP) or Individualized Family Service Plan (IFSP) it must be submitted along with the DD 2792-1. If unsure, ask the parents if the child has 504, IEP, or IFSP.

6. Contact Information Additional Information can be obtained from Merri Bair. She can also be reached at 757- 953-2935. Merri Bair