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Student's Name |
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Date of Meeting |
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By mutual agreement between the parent/adult student, and designated representative of the
local education agency, the presence and participation of the Individual Education Program
team member(s) identified below is/are not necessary and has/have been excused from
being present and participating in the meeting scheduled on
because (1) the member’s area of the curriculum or related services is not being modified
or discussed in the meeting or (2) the meeting involves a modification to or discussion of the
member’s area of curriculum or related services and the member submitted, in writing to the
parent and the IEP team, input into the development of the IEP prior to the meeting.
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Individual Education Program Team Member(s) |
Area Of Curriculum Or Related Services |
Check appropriate column explaining why the IEP team member is being mutually excused
from the IEP meeting in whole or part:
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Area Of Curriculum Or Related Services is Not Being Discussed or Modified
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Written input has been submitted to the parent and the IEP team prior to the meeting
regarding the Area of Curriculum or Related Services.
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By mutual agreement the IEP team members identified above,
have been excused from being present and participating in my child’s IEP meeting.
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CIRCLE relationship to student, sign, and date below.
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Signature of Parent/Guardian/Surrogate: |
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Date: |
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Signature of Parent/Guardian/Surrogate: |
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Date: |
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Signature of Adult Student (ages 18-21): |
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Date: |
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Signature of Designated District Representative: |
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Date: |
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