IEP Team Amendment(s) Page
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Name Birthdate IEP date
 

 
  Parents/Guardians/Surrogates have agreed that a meeting is not needed for this amendment.  
 
  Purpose of Meeting Purpose of Meeting     
 
  Amendment(s) to the IEP dated Amendment(s) to the IEP dated   :  
 

 
  Amendment(s)   Type of Service   Frequency/Duration
(e.g., days pwer week/minutes)
  Location and Provider   Goals
Effective date: Effective date:  
 
 
 
         
(see attached goals)
 
         
(see attached goals)
 
 

 
   
 

 
_____ I agree to all parts of this amendment to the IEP dated  
 
_____ I agree to this amendment to the IEP dated , with the exception of  
 
_____ I do not agree with this amendment to the IEP dated  
 
_____ I have been advised of and given a copy of the Notice of Procedural Safeguards, as required once per year.
 
         


 

Parent/Guardian/Surrogate Date   Parent/Guardian/Surrogate Date
         


 

LEA Rep./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