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.