| Student Name: __________________________________
Date Services Begin: ______________________________
Date Services End: ________________________________
Initial Agreement: _________________________________
Modified Agreement: ______________________________
I am writing as a follow-up on our recent evaluation concerning your child and to summarize our recommendations and agreements for aids, services or accommodations. The aids, services or accommodations are as follows:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
The following procedures need to be followed in the event of a medical emergency:
______________________________________________________________________
______________________________________________________________________
The attached letter outlines your rights to resolve any disputes that you may have concerning the recommended aids, services or accommodations. If you have any questions concerning your rights or the aids, services or accommodations recommended, please feel free to contact me.
| ________________________ |
________________________ |
| School District Administrator |
Date |
DIRECTIONS: Please check one of the options and sign this form.
_____ I agree and give permission to proceed as recommended.
_____ I do not agree and do not give permission to proceed as recommended.
_____ I would like to schedule an informal conference to discuss my concerns.
My reason for disapproval is: ____________________________________________
_______________________________________________________________________
| ________________________ |
________________________ |
| Parent(s) Signature |
Date |
July 1, 1999 -- 22 Pa. Code Chapter 15 | 
