To: Parent, Student File

PERMISSION FOR REVIEW

(Student Identified Under IDEA or Section 504)

I, __________________________________________ , hereby give my permission for the

Parent/Legal Guardian/Surrogate

_______________________________________ to respond to a request for assistance

School District

for ________________________________________.
Name of Child

I understand that giving my permission is voluntary on my part and I may revoke my permission, except to
the extent that action has already been taken in reliance thereupon. In giving my permission, I understand
that the activities indicated below will occur:

_____ Review of relevant records (releases of information will be included);

_____ Interviews with caregiver or myself;

_____ Observation(s) of my child:

_____ Assessment (e.g., curriculum-based, screening, and other appropriate measures to determine
interventions); and/or

_____ Other (specify): __________________________________________________________

_____________________________________________________________________________

I further understand and agree that the information collected by the school district will then be reviewed
and the team will determine if interventions are needed. If interventions are needed, the team will
develop an intervention plan and designate the resources needed to implement these interventions.

I understand that because my child is currently identified under either the IDEA or Section
504, this permission for review is being utilized to give permission for the activities noted
above, and that these activities do not constitute an evaluation or reevaluation. However,
the information collected by the school district will be reviewed by my child’s IEP or Section
504 team and will be utilized to aid in making educational decisions for my child.

______________________________________
Name of Parent/Legal Guardian/Surrogate

______________________________________
Signature

_____________________
Date