Iep Commitment Signatures Form

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Student Name__________________________________Date of Birth_______________Date of IEP_________________Page_______
Commitment Signatures
Any IEP Team member may submit a dissenting report for attachment to this IEP Team Report.
Resident District – Resident district superintendent/designee (check all that apply):
Agrees with the IEP and its implementation
Disagrees with the IEP and:
Authorizes the nonresident operating district to conduct subsequent IEP Team meetings
requests mediation
Agrees that the student is not eligible for special education
(see below)
Signed: _________________________________________________________________
Date: __________________________
Resident District Superintendent or Designee
month/day/year
Non-resident Operating District – The superintendent/designee (check all that apply):
Agrees to provide the IEP program(s) and/or service(s)
Disagrees with the IEP and:
Agrees to conduct subsequent IEP Team meetings
requests mediation
Agrees that the student is not eligible for special education
(see below)
Signed: _________________________________________________________________
Date: __________________________
Operating District Superintendent or Designee
month/day/year
Notice Requirements
The superintendent or designee of the operating district assures that:
(a) to the maximum extent appropriate, a person who has a disability, including a person who is assigned to a public or private institution or
other care facility, is educated with persons who do not have disabilities.
(b) placement of a person who has a disability in special classes, separate schools, or the removal of a person who has a disability from
the general education environment occurs only when the nature or severity of the disability is such that education in a regular class
using supplementary aids and services cannot be satisfactorily achieved.
(c) the placement for the student is as close as possible to his or her home.
(d) unless the IEP of a student with a disability requires some other arrangement, the student is educated in the school that he or she
would attend if nondisabled.
(e) in selecting the least restrictive environment, consideration shall be given to any potentially harmful effects to the student or the quality
of services that the student needs.
(f) a student with a disability will not be removed from education in age-appropriate regular classrooms solely because of needed
modifications in the general education curriculum.
Staff responsible for implementation: _______________________________ Initial implementation site: ___________________________
Beginning date (month/day/year): ______________________________ Ending date (month/day/year): ___________________________
Signed: ______________________________________________________________________ Date: ___________________________
Superintendent or Designee
month/day/year
Adult Providing IEP Consent-I have been provided with procedural safeguards and sources to obtain assistance, and:
Understand the contents of this IEP
Disagree, but will allow implementation of this IEP
Agree with the IEP and its implementation
Disagree with this IEP and:
requests mediation
(see below)
Signed: ___________________________________________________________________
Date: __________________________
Adult Providing Consent
month/day/year
Student Signature: __________________________________________________________
Date: __________________________
month/day/year
If a parent or public agency disagrees with the IEP, either party has the right to request a due process hearing
by following the procedures outlined in the Procedural Safeguards.
Copy distribution:
LISD
Sp. Ed. Teacher
Parent(s)
Local District (CA 60 file)
March 2011 Rev.
Form 10

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