Request For Appointment Of Educational Surrogate Parent printable pdf download

Request For Appointment Of Educational Surrogate Parent

South Bend Community School Corporation

Special Education Services

215 S. St. Joseph St, South Bend, IN 46601

Ph: 574.283.8130 Fax: 574.283.8105

Request for Appointment of Educational Surrogate Parent

Student Name: __________________________ SBCSC ID#: ______________ STN#: ____________________

School: ________________________________ DOB: ___________ Disability: ___________________________

Student lives with: _______________________ Relationship: _________________________________________

Address: ___________________________________________________________________________________

___________________________________________________________________________________________

Phone Number: ________________________ Teacher of Record:______________________________________

This student needs a surrogate parent for the following reason: ________________________________________

___________________________________________________________________________________________

Is the person the student is living with willing to be trained and appointed as the educational surrogate parent?

____Yes

____ No ____ Not qualified

____ Other

Do you know where parents are?

____ Yes

____ No

If yes, please give parent’s name:

________________________________________________________

Address:

________________________________________________________

Is there a court order or other legal document giving custody/guardianship? If yes, please attach a copy.

____________________________________

__________________________________________

Name of Person Completing Form

Date

Please submit this request to Special Education Services and we will follow up with appointing an

educational surrogate parent for this student. A copy of the Appointment of Educational Surrogate Parent

will be sent to the school.

Copy to: surrogate, cum, TOR and original to Special Ed Services

8/19/12

Request For Appointment Of Educational Surrogate Parent