Surrogate Parent Appointment Form

SURROGATE PARENT APPOINTMENT FORM

Ionia County Intermediate School District

Child’s Name: DOB

Caseworker: Agency:

The purpose of this form is to facilitate the delivery of special education or early intervention services provided within the jurisdiction of Ionia County Intermediate School District to the child listed above, and to ensure that this child’s rights are protected. This agreement will become void if a person is legally appointed to act in place of the parent, the location of the biological parent(s) becomes known or either party chooses to terminate this agreement (per Michigan Department of Education guidelines).

Criteria for Selection of Surrogate Parent

Both parties certify that to the best of their knowledge the surrogate parent is not an employee of any agency that is involved in the education or care of the child, has no interest that conflicts with the interest of the child he or she represents and has knowledge and skills that ensure adequate representation of the child. If the need for a surrogate parent is due to an inability to discover the whereabouts of the parent, efforts by the public agency to locate the parent are described as follows;

Responsibilities of Surrogate Parent

The surrogate parent is expected to represent the child in all matters relating to the identification, evaluation and educational placement of the child; and the provision of a Free Appropriate Public Education (FAPE) to the child.

Consultation to assist the surrogate parent may be obtained by contacting the Planner/Monitor at Ionia County Intermediate School District at (616) 527-4900.

I certify that I understand and agree with the contents of this form and agree to be a surrogate parent for the child named on this form.

Surrogate Parent Signature: Date:

I certify that surrogate parent requirements have been met and approve the appointment of the above person as surrogate parent for the child named on this form.

Public Agency Representative: Date:

Copies: Surrogate Parent Operating School District Intermediate School District