IEP TEAM MEMBER EXCUSAL
From A Meeting In Whole Or In Part

 
  Student's Name ,
   
  Date of Meeting
   
 
By mutual agreement between the parent/adult student, and designated representative of the local education agency, the presence and participation of the Individual Education Program team member(s) identified below is/are not necessary and has/have been excused from being present and participating in the meeting scheduled on because (1) the member’s area of the curriculum or related services is not being modified or discussed in the meeting or (2) the meeting involves a modification to or discussion of the member’s area of curriculum or related services and the member submitted, in writing to the parent and the IEP team, input into the development of the IEP prior to the meeting.
 

 
Individual Education Program Team Member(s) Area Of Curriculum Or Related Services Check appropriate column explaining why the IEP team member is being mutually excused from the IEP meeting in whole or part:
Area Of Curriculum Or Related Services is Not Being Discussed or Modified Written input has been submitted to the parent and the IEP team prior to the meeting regarding the Area of Curriculum or Related Services.
 

 
By mutual agreement the IEP team members identified above, have been excused from being present and participating in my child’s IEP meeting.
 
CIRCLE relationship to student, sign, and date below.
 
Signature of Parent/Guardian/Surrogate:     Date:     
 
   
 
 
Signature of Parent/Guardian/Surrogate:     Date:     
 
   
 
 
Signature of Adult Student (ages 18-21):     Date:     
 
   
 
 
Signature of Designated District Representative:     Date:     
 
   
 
 
Title/Position