Childrenwith Disabilitiesenrolled Bytheirparents in Privateschoolnotificationof Parentalintent

SONOMA COUNTY SELPA

Childrenwith DisabilitiesEnrolled ByTheirParents in PrivateSchoolNotificationof ParentalIntent

Student'sname: DOB:______
DistrictofResidence: PrivateSchoolofAttendance:______

Checkoneofthefollowingboxes:

InitialAssessment

Ihaveaninterestinenrollingmychildinapublicplacement.IreceivedmyParentalRightsandProceduralSafeguardsforSpecialEducation.TheEvaluationPlanyouprovidedissignedandenclosed.PleasecontactmetoscheduletheEvaluationandIndividualizedEducationProgram(IEP)teammeetingtodevelopanIEPformychild.

Three-YearRe-Evaluation

Ihavenointerestinenrollingmychildinapublicplacement.Iintendtomaintainmychild'senrollmentinprivateschool.Iunderstandthatmydistrictofresidencecontinuestomakeafreeappropriatepubliceducationavailabletomychild.

Ifyoucheckedthisoption,please checkoneofthefollowingboxes:

TheSELPAindicatesthataThree-YearRe-Evaluationisnecessary.Iagree.IherebyrequestanEvaluationto determinewhethermychildcontinues tobe eligibleforspecialeducationand relatedservices.I received myParentalRightsandProceduralSafeguardsforSpecialEducation.TheEvaluationPlanyou providedissigned andenclosed.Please contactme to scheduletheEvaluation.

TheSELPAindicatesthataThree-YearRe-Evaluationisnecessary.However,IherebydeclineanEvaluation to determinewhethermychildcontinuestobe eligibleforspecialeducationandrelated services. IunderstandthatmychildwillnotreceiveservicespursuanttoaSELPAServicePrivatePlan.

TheSELPAindicatesthata Three-YearRe-Evaluationisnotnecessary.Iagree.I herebydecline anEvaluation todeterminewhether mychildcontinuestobeeligibleforspecial

educationandrelatedservices.

TheSELPAindicatesthata Three-YearRe-Evaluationisnotnecessary.Idisagree.IherebyrequestanEvaluationtodeterminewhether mychild continuestobe eligibleforspecialeducation and related services.Pleasecontact meto proposeanEvaluationPlan.

Checkoneofthefollowingboxes:

MychildhasaPrivate ServicePlan.Iconsenttomychild'scontinuedreceiptofservicespursuanttohis/herPrivateServicePlan.

MychildhasaPrivateServicePlan.Ideclinemychild'scontinuedreceiptofservicespursuanttohis/herPrivateServicePlan.

MychilddoesnothaveaPrivate ServicePlan.PleasecontactmetoscheduleameetingtodevelopaPrivateServicePlan,ifappropriate,formychild.

MychilddoesnothaveaPrivateServicePlan.IdonotwanttoscheduleameetingtodevelopaSELPAServicePlanatthistime.

Parent Print Name Parent Signature

Daytime Phone Evening Phone_ Date