Signature and Parent Consent
Name ,   Date

Meeting Participants
       
 

 

  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
           
       
 

 

  Additional Participant/Title Date   Interpreter/Translator Date

PARENT CONSENT (please initial initial areas of agreement)
 
____ I participated in the development of the IEP
 
____ 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 give my permission for the school district or SELPA to bill Medi-Cal for eligible services provided at no cost to parents.
 

____ I understand that my child is no longer eligible for special education.

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