PARENT NOTIFICATION AND CONSENT TO DETERMINE ELIGIBILITY FOR ACCOMMODATIONS

Date of Referral:_______________________________

Student:______________________________________

School:______________________________________

Date of Birth:________________________________ Sex:____________ Grade:_____________

Home Address:________________________________ Home Phone:______________________

Teacher/Counselor:________________________________

Parent/Guardian:__________________________________

______________________________________________________________________________________

Please Circle One

Yes  No  I have received and understand the statement of Parental Rights.

Yes  No  I give my consent to have my child evaluated.

Parent Signature: ____________________________________________________________

Please return this letter to: _____________________________________________________

______________________________________________________________________________________

For office Use Only

Date of Receipt of Consent:_____________________________________________

School Official:______________________________________________________