PARENT CONSENT FOR EVALUATION
Title For Admin *Initial EvaluationReevaluation (if additional assessment is to be conducted) Part I: Consent I have read my procedural safeguards & I understand my rights. If you consent type I CONSENT * FOR an Evaluation for (child's name) * I CONSENT for my child to receive an evaluation(s) by designated personnel. I CONSENT & I understand the evaluation data is shared with teachers, principals, & other appropriate school personnel. I CONSENT & I understand that the school district will forward educational records upon request to new school district or educational agency where my child seeks or intends to enroll. I CONSENT & I understand that my CONSENT is voluntary on my part & I may revoke my CONSENT at any time. Signature of Parent/Legal Guardian/Custodian, or Student (if age 18 or older) * Relationship to Child * Date (mm/dd/yyyy) * Part III: (To be completed by school) Information about the evaluation & a copy of the Procedural Safeguards Notice were given by Signature of School District Representative * Date(s) (separated by commas) (mm/dd/yyyy) * The Parent's Native Language is * If Not English, was the Data Provided in the Native Language or Other Mode of Communication of the Parents? *----------NA----------YesNo If No, explain (if not applicable type NA) * If the Native Language or Other Mode of Communication is Not a Written Language, Attach Documentation of the Steps Taken to Ensure that the Notice was Explained & that the Parent Understands the Content of the Notice. Effective date: 2/1/07