Permission For A Newly Enrolled Student To Receive Special Education Services
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1SOUTH BEND COMMUNITY SCHOOL CORPORATION
Special Education Department
215 South St. Joseph Street, South Bend, IN 46601
Phone: 574-283-8130 FAX: 574-283-8105
PERMISSION FOR A NEWLY ENROLLED STUDENT
TO RECEIVE SPECIAL EDUCATION SERVICES
Name:
DOB:
Address:
Phone:
_____ I give _____ I do not give permission to the South Bend Community School Corporation to provide
special education and related services to this student. These services will be determined by school staff based
on observations of the student and a review of information received (either in records and/or by telephone) from
the previous school.
According to information from the parent/guardian and/or previous school district, this student is eligible for
services under the disability(ies) of _____________________________________ at this time.
Services will be provided at _______________________________ school and will begin on
__________________. A case conference will be convened within 10 school days to develop an Individual
Education Plan which will provide the student with a Free and Appropriate Public Education according to federal
and state law.
I have received a copy of the "Notice of Procedural Safeguards" with explanation.
Signed:
Parent or legal guardian
Date
Approved:
Building Principal
Date
Rev. 10/07
Copy to parent, cum, TOR and original to Special Ed Dept.
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