Signature and Parent Consent (6A)
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Name   IEP Date
 

 
IEP Meeting Participants
 
     


 

Parent Date   Parent Date
         
     


 

LEA Representative/Admin. Designee Date   General Education Teacher Date
         
     


 

Student 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
 

 
Parent Consent
 
____ I agree to all parts of the IEP
 
  ____ I agree with the IEP, with the exception of  
 
____ I understand that my child is NOT eligible for special education.
 
____ I understand that my child is NO LONGER eligible for special education.
 

 
Signature below is to authorize and approve the IEP.
 
  Signature:   Date:  
   
   
  Relation  (if other, specify:)      
           
  Signature:   Date:  
   
   
  Relation  (if other, specify:)      
 
Did the school district facilitate parent involvement as a means of improving services and results for your child?  Yes ___  No ___
 

 
 
____ 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.
 
 
 
  Parent Signature  
 

 
Student enrolled in private school by their parents. Refer to Individual Service Plan, if appropriate.