Form M - Parent/guardian Consent For Initial Provision Of

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PARENT/GUARDIAN CONSENT FOR INITIAL PROVISION OF
SPECIAL EDUCATION AND RELATED SERVICES
DATE: _________________ STUDENT’S NAME: __________________________STUDENT’S DATE OF BIRTH: ________________
Dear _____________________________________:
(Parent’s/Guardian’s Name)
At a recent conference your child was recommended for initial provision of special education and related services and an
Individualized Education Program (IEP) was developed.
Before a school district can provide the special
education services described in your child’s IEP, your informed written consent is required.
Your consent
is
voluntary
and
you
may
revoke
your
consent
at
anytime.
If
you
revoke
consent,
it
does
not
negate an action that has occurred after the consent was given and before the consent was revoked.
CHECK ONE:
I give consent
For the following initial special education and related services of my child as
indicated on the Individualized Education Program (IEP). The proposed special
education and related service(s) have been fully explained to me and are consistent
with the IEP developed for my child.
I understand that my consent is voluntary. I understand that my consent is not required
for continued services or change in services/placement. At least annually, I will be
given reasonable opportunity for comment on and input into my child’s IEP.
I received a copy of the Explanation of Procedural Safeguards which have been fully
explained to me by school personnel, including the procedures for requesting an impartial
due process hearing.
I understand that as soon as possible following development of the IEP, but not more
than ten (10) calendar days, special education and related services will be provided to my
child in accordance with the IEP.
I do not give consent
For the following special education and related services of my child as indicated in the
Individualized Education Program (IEP).
I understand that the school district will not be in violation of the requirement to make
available a free appropriate public education for my child if I refuse to give consent.
I have received
Copy of the IEP Eligibility Summary
Copy of the Individualized Education Program (IEP)
Other _______________________________________
Date: ________________________
Parent/Guardian Signature: ___________________________________
If you have any questions concerning this process or require additional information regarding your and your child’s rights,
please contact:
Name: _________________________ Title: ____________________________________ Phone: _________________
Sincerely,
___________________________________________
(Signature)
Name: _____________________________________
Title: ______________________________________
ISBE 34-57F (4/08)
Form M
BASSC: Belleville Area Special Services Cooperative Phone: (618) 355-4700

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