IEP 5 SIGNATURE AND PARENT CONSENT
Name Birthdate Date

       
 

 

  LEA Representative Date   General Education Teacher Date
           
       
 

 

  IEP Chairperson/Administrative Designee Date   Special Education Specialist Date
           
       
 

 

  Student 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   Interpreter/Translator Date

PARENT CONSENT (please initial initial areas of agreement)
   
____ I participated in the development of the IEP
____ If this is an initial/triennial IEP, I have received & reviewed the evaluation report.
____ I agree to all parts of the IEP or ____ I agree with the IEP, with the exception of
____ I have received and have been given an opportunity for a full explanation of the Procedural Safeguards.

____ I understand that my child is no longer eligible for special education. Exit Reason (Code):

____ On or before the student's 17th birthday, he/she has been advised of rights at age of majority (age 18).
     
 
 
 
  Date Date   By Whom  

 

  Signature:   Date:    
   
   
 
  Relation        
             
  Signature:   Date:    
   
   
 
  Relation        
Parent requested a copy of IEP in primary language: Parent requested a copy of IEP in primary language:
 
Student enrolled in private school by their parents. Refer to Individual Service Plan, if appropriate.