Parent/Guardian Name(S) Date Form Sent Date Form Received

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Student name Age Grade level

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Parent/Guardian Name(s) Date form sent Date form received

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Parent/Guardian address

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Second Parent/Guardian address (if form mailed separately)

Dear Parent or Guardian:

You have received this form because the District is proposing to reevaluate you child for the following reason(s):

□ To determine whether your child continues to have a disability within the meaning of Section 504 of the Rehabilitation Act of 1973 and Chapter 15 of the regulations of the Pennsylvania State Board of Education or to determine the current educational needs of your child;

□ To a request of a parent or guardian for a reevaluation.

We have reviewed all available existing information concerning your child and his or her educational needs, and have determined that we require additional information to determine whether your child continues to have a disability or to determine his or her educational needs. We are asking that you consent to allow us to conduct the following tests and assessment procedures:

Upon completion of these tests and assessments, the District will prepare a written report of its findings and conclusions and share that report with you. Your concerns and any information you have about your child, particularly as they relate to school performance and participation, will be a valuable part of the evaluation and the resulting evaluation report. We cannot proceed with these important tests and assessments without your consent. If you have any questions or concerns about the proposed testing and assessment procedures, do not hesitate to contact me at (___) ___-____ or at ______@______. Please indicate your preference below and return this form to me at ______. An explanation of the procedural safeguards that protect you as the parent of a child thought to have a disability are enclosed with this form or attached to the electronic mail message with which this form was sent.

□ I consent to the evaluation as Very truly yours,

proposed above

□ I do not consent to the evaluation ______

proposed above and wish to schedule Signature staff member sending this form

an informal conference to discuss it ______

Printed name and position of staff member

Form developed March 2010