REQUEST FOR SPECIAL EDUCATION MEDIATION

REQUEST FOR SPECIAL EDUCATION MEDIATION
Wisconsin Special Education Mediation System (WSEMS)

INSTRUCTIONS: Complete and submit one (1) signed copy. Once signed, this form will automatically be submitted to:

WISCONSIN SPECIAL EDUCATION MEDIATION SYSTEM
Gia Pionek
PO BOX 70693
Milwaukee, WI 53207

Email: gia@wsems.us
Website: wsems.us
(Attach additional page if needed) We wish to request that WSEMS will convene a special education mediation session regarding the following unresolved issues
Name of School District Administrator or Designee
Name of School District
Address
City
State
Zip
Telephone Area/No.
Format: (000) 000-0000.
E-mail
example@example.com
Name of Student
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Parents/Guardians
Address
City
State
Zip
Telephone Area/No.
Format: (000) 000-0000.
E-mail
example@example.com
We understand mediation is a voluntary dispute resolution option available to encourage early resolution of issues whenever possible. We understand that mediation may not delay or deny the right to a due process hearing or IDEA complaint. We understand that mediation is confidential and that the information will not be shared with others. We understand that signing this request gives the WSEMS mediator, Intake Coordinator, and System Administrator access to information about the student, including information from the IEP document, disability information, and school day schedule.
Signature of School District Administrator or Designee
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
The individual listed above is the primary school district contact? If not, please list their name and email address

Other
Signature of a Parent/Guardian/Adult Student
Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
8/1/26 The Wisconsin Special Education Mediation System (WSEMS), CFDA #84.027A, acknowledges the support of the Wisconsin Department of Public Instruction in the development of the system and for the continued support of this federally-funded grant project. There are no copyright restrictions on this document; however, please credit the Wisconsin DPI and support of federal funds when copying all or part of this material.
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