Parent Report of Special Services (new student only)

Parent Report of Special Services

(new students only)
Student Name*
School*

Glen Rose KindergartenGlen Rose ElementaryGlen Rose MiddleGlen 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).

NoYes
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.

NoYes
My child has a current Individualized Education Program (IEP) for the following special education services (check all that apply):

resource classself-contained classspeech-language therapyoccupational therapyphysical therapybehavior plancounselingOther
My child has a current Section 504 Plan for the following services (check all that apply):

classroom accommodationstesting accommodationsspeech-language therapyoccupational therapyphysical therapybehavior plancounselingOther
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*
Date*

MonthDayYear
Date
DISTRICT USE ONLY
Date

MonthDayYear
Date
Reviewed by
Date

MonthDayYear
Date
Parent contacted by
Date

MonthDayYear
Date
Parent Rights given by
Parent Rights provided

in personmailedemailedsent with studentrefused
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