Consent Form - Sample

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

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[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: