• Geneva City School District Office of Student Services

    SAMPLE Student Services Consent for Initial Evaluation
     

    Below is a sample of the form a parent/guardian would be asked to sign


    [DATE]

    RE:

    DOB:

    ID#:

    I have received and understand the notice that my child has been referred to the Committee on Special Education for evaluation to determine if my child has a disability that may require special education services. I understand that I must give written consent to the district in order for my child to be evaluated.

    I have also received a copy of the Procedural Safeguards Notice.

    Please check one box:

    □ I hereby grant consent for evaluation by the Committee on Special Education as indicated below:

    [Psychological Evaluation]

    □ I do not consent for evaluation by the Committee on Special Education.                                                              

    Parent/Guardian Name:

    Signature:

    Date: