Signature and Parent Consent (6A)
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Name
IEP Date
IEP Meeting Participants
Parent/Guardian/Surrogate
Date
Parent/Guardian
Date
Student/Adult Student
Date
General Education Teacher
Date
LEA Representative/Admin. Designee
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
Consent
____
I agree to all parts of the IEP
____
I agree with the IEP, with the exception of
____
I decline the offer of initiation of special education services
____
I understand that my child is
not
eligible for special education.
____
I understand that my child is
no longer
eligible for special education.
As a means of improving services and results for your child did the school facilitate parent involvement?
As a means of improving services and results for your child did the school facilitate parent involvement?
As a means of improving services and results for your child did the school facilitate parent involvement?
Signature below is to authorize and approve the IEP.
Signature:
Date:
Relation
Relation
Relation
(if other, specify:)
Signature:
Date:
Relation
(if other, specify:)
If my child is or may become eligible for public benefits (Medi-Cal): I authorize the LEA/District to release student information for the limited purpose of billing Medi-Cal/Medicaid and to access Medi-Cal health insurance benefits for applicable services.
If my child is or may become eligible for public benefits (Medi-Cal): I authorize the LEA/District to release student information for the limited purpose of billing Medi-Cal/Medicaid and to access Medi-Cal health insurance benefits for applicable services.
If my child is or may become eligible for public benefits (Medi-Cal): I authorize the LEA/District to release student information for the limited purpose of billing Medi-Cal/Medicaid and to access Medi-Cal health insurance benefits for applicable services.
Signature:
Parent has received a copy of the Procedural Safeguards
Parent has received a copy of assessment report (if applicable)
Parent has received brochure and application for the Community Advisory Committee (CAC) for Special Education.
Parent has received a free copy of the IEP. Parent has received a copy of the Individualized Education Plan (IEP).
Parent has received written notification of protections available to parents when LEA requests to access Medi-Cal benefits.
Student enrolled in private school by their parents. Refer to Individual Service Plan, if appropriate.