Withdrawal Of Request For Evaluation printable pdf download

Withdrawal Of Request For Evaluation

South Bend Community School Corporation

Special Education Services

215 S. St. Joseph St, South Bend, IN 46601

Ph: 574.283.8130 Fax: 574.283.8105

Date: _______________________

Dear Parent/Guardian:

We have been informed that you are withdrawing your request/permission for the South Bend

Community School Corporation to complete an evaluation on your child.

If this is the case, please sign below and return this letter in the self-addressed, stamped envelope.

As parent and legal guardian of ________________________, DOB ________, who attends

________________________ school, I am withdrawing my request for an evaluation.

I understand that, if in the future, I wish to request an evaluation, I can do so by making a request to any

certified staff member at my child’s school. I also understand that the required procedures for an initial

evaluation as described in state law will be followed.

____________________________________________________

_______________________________________

Parent/Guardian Signature

Date

Cc: principal, cum, psychologist

8/19/12

Withdrawal Of Request For Evaluation