REFUSE CONSENT FOR EVALUATION
Title Part II: Refuse Consent Do Not Complete Part II if you completed Part I I have read my Procedural Safeguards & I understand my rights. If you do not consent type I DO NOT CONSENT * For an Evaluation for (child's name) * Reasons: If you share with us your reasons for NOT CONSENTING, then the district may be able to meet your child's unique needs later. (if not applicable type NA) * 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