Signature and Parent Consent (6)
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Name   IEP Date
 

 
IEP PARTICIPANTS, PLEASE PRINT NAME(S):   IEP PARTICIPANTS, PLEASE SIGN AND DATE:
 
       

 
Parent/Guardian/Surrogate (Print Name) Signature Date
 
 

 
Student (Print Name) Signature Date
 

 
Special Education Specialist (Print Name) Signature Date
 

 
General Education Teacher (Print Name) Signature Date
 

 
LEA Representative/Admin. Designee (Print Name) Signature Date
 
 

 
Additional Participant/Title (Print Name & Title) Signature Date
 
 

 
Additional Participant/Title (Print Name & Title) Signature Date
 
 

 
Additional Participant/Title (Print Name & Title) Signature Date
 
 

 
Interpreter/Translator (Print Name) Signature Date
 

 
  CONSENT (Please initial areas of agreement):
 
  ____ participated in the development of the IEP. _____ I have received a copy of my Procedural Safeguards.
 
  ____ I agree to all parts of the IEP  or
 
  ____ I agree to all parts of 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:)        
 

 
 
  ____ Only applicable if my child is eligible or may become eligible for public benefits (Medi-Cal): I authorize district access to bill Medi-Cal, if there is no cost to me.  
 
 
   
  Parent Signature    
 

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