Form 6a - Signature And Parent Consent
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1STATE SELPA IEP TEMPLATE
SIGNATURE AND PARENT CONSENT
Student Name _____________________
Date of Birth ___/___/________
IEP Date ___/___/________
IEP MEETING PARTICIPANTS
_________________________________
___/___/______
_________________________________
___/___/______
Parent / Guardian / Surrogate
Date
Parent / Guardian
Date
_________________________________
___/___/______
_________________________________
___/___/______
Student / Adult Student
Date
General Education Teacher
Date
_________________________________
___/___/______
_________________________________
___/___/______
LEA Representative/Admin. Designee
Date
Special Education Specialist
Date
_________________________________
___/___/______
_________________________________
___/___/______
Additional Participant/Title
Date
Additional Participant/Title
Date
_________________________________
___/___/______
_________________________________
___/___/______
Additional Participant/Title
Date
Additional Participant/Title
Date
_________________________________
___/___/______
_________________________________
___/___/______
Additional Participant/Title
Date
Additional Participant/Title
Date
CONSENT
_______ I agree to all parts of the IEP.
_______ I agree with the IEP, with the exception of ________________________________________________________________
_______ I decline the offer of initiation of special education services.
_______ I understand that my child is not eligible for special education.
_______ I understand that my child is no longer eligible for special education
As a means of improving services and results for your child did the school facilitate parent involvement?
Yes
No
No Response
Signature below is to authorize and approve the IEP.
Signature____________________________________________________
___/___/______
Parent
Guardian
Surrogate
Adult Student
Date
Signature____________________________________________________
___/___/______
Parent
Guardian
Surrogate
Adult Student
Date
If my child is or may become eligible for public benefits (Medi-Cal): I authorize district to access Medi-Cal: health insurance benefits for
applicable services.
Yes
No
Parent / Guardian Signature _____________________________________________________________
Parent has received a copy of the Procedural Safeguards
Parent has received a copy of assessment report (if applicable)
Parent has received a copy of Individualized Education Plan (IEP)
Parent has received written notification of protections available to parents when LEA requests to access Medi-cal benefits
Student enrolled in private school by their parents. Refer to Individual Service Plan, if appropriate.
Revised 7/2013
Form 6A
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