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.