Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

What is your relation to the student? *

Parent

Legal Guardian

Do you share decision-making rights with another parent? *

Yes

No

1. My child has an IEP. *

Yes (if yes, please indicate eligibility in 1A and 1B)

No (if no, skip to question 4)

2. IEP Date

MM

DD

YYYY

3. Triennial Date

MM

DD

YYYY

4. My child has a 504 plan. *

Yes

No (if no, skip to question 5)

5. Has your child been evaluated for Special Education or 504 services? *

I have requested that my child be evaluated.

My child is currently being evaluated.

My child was evaluated and found eligible for Special Education or a 504 Plan.

My child was evaluated but not found eligible for Special Education Services or a 504 Plan.

My child has not been evaluated for Special Education Services or a 504 Plan.