Parent Consent Form (Sample) printable pdf download

Parent Consent Form (Sample)

Parent Consent Form

(Sample)

Your child has been recommended to participate in the English as a Second Language

(ESL) program. The ESL program is designed to help your child learn English in order to

be successful in the classroom. The school district wants to provide the best educational

program for your child.

The decision to place your child in ESL is based on the results of the home language

survey, language assessment test scores and/or student and parent interviews.

The District offers several programs to students who qualify for language assistance.

Newcomer Program

• ESL Program in the home school

• Extended day kindergarten

• Mainstream classroom instruction

You do have the right to refuse enrollment in the ESL program. This means that your

student will not be taught English in a special program.

The following topics regarding your child’s education have been discussed with you

during this meeting:

• The reasons for determining that your child needs the special instructional

services that the English as a Second Language program offers.

• The program services that are available.

• A description of the program services.

• The option to decline enrollment in the program.

___ These items have been discussed with you.

___ Yes, my child may participate.

___ No, I choose to refuse the services of the ESL program.

Student Name: __________________________________________________

Name of Legal Guardian (please print): _________________________________

Signature of Legal Guardian: ________________________________________

Date: ____________________________

Parent Consent Form (Sample)