Parent Report of Special Services (new student only)

Parent Report of Special Services

(new students only)
Student Name *
School *

Glen Rose Kindergarten Glen Rose Elementary Glen Rose Middle Glen Rose High
My child has never received special services through an Individualized Education Program IEP or Section 504 plan (including speech, occupational, &/or physical therapy).

No Yes
My child has previously received special services through an Individualized Education Program (IEP) or Section 504 plan (including speech, occupational, &/or physical therapy), but no longer receives them.

No Yes
My child has a current Individualized Education Program (IEP) for the following special education services (check all that apply):

resource class self-contained class speech-language therapy occupational therapy physical therapy behavior plan counseling Other
My child has a current Section 504 Plan for the following services (check all that apply):

classroom accommodations testing accommodations speech-language therapy occupational therapy physical therapy behavior plan counseling Other
Previous school district *
I give my permission for the Glen Rose School District to contact my child's previous school(s) regarding special education and/or Section 504 records. I give my permission for my child's previous school(s) to share pertinent information and records with the Glen Rose School District for the purpose of appropriate placement and educational programming.
Parent/Guardian Name
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
DISTRICT USE ONLY
Date

Month Day Year
Date
Reviewed by
Date

Month Day Year
Date
Parent contacted by
Date

Month Day Year
Date
Parent Rights given by
Parent Rights provided

in person mailed emailed sent with student refused
Should be Empty: