(PROTOTYPE) INDIVIDUALIZED Student Information _x_ Draft 04/21/2016
EDUCATION PLAN (IEP)
Region: VII Central Visayas
School: Paref Southdale School
STUDENT AND SCHOOL INFORMATION
First Name: Tom
Middle Name: Julie
Last Name: Cruise
Address: 245 Plaridel St., San Nicolas
City/Municipality: Cebu City
Province: Cebu Zip Code:6000
Grade: Grade I
Learner Reference No. 117496140047
Date of Birth: 10/15/2007
Age: 10 Gender: _X__ Male __ Female
RACE
Ethnicity: Asian
Student Identified as Limited Local Language
Proficient:
____ Yes _X No.
Student’s Native Language: Sinugbuanong
Binisaya
Local Municipality/City: Cebu City
Local School: Banilad Elem. School
Is the student currently under the custody of
an accredited DSWD agency? ___ Yes _X No
If yes name the agency: _________________
Does the student require a parent surrogate?
______ Yes ___X__ No
Parent Surrogate Name:
______None______________
Surrogate Phone:
_____NA_________________
__ Approved ________
__ Amended ________
Division: Cebu City
IEP Meeting Date: 05/01/2016
PARENT/GUARDIAN 1
First Name: Kate MI T.
Last Name: Holmes
Cell #: 09095783112
Parent Native Language: Sinugboanong
Binisaya
Interpreter Needed? ____ Yes _X_ No
Parent/Guardian 2
First Name: James . MI.
Last Name: Reed
Parent Native Language: Sinugboanong
Binisaya
Interpreter Needed? ____ Yes __X_ No
Case Manager: Ms. Robi Imbo
IEP Team Meeting Date(s) 05/01/ 2016
IEP Annual Review Date: _04/30/2017
Parents were provided with verbal and
written information about access to services,
including a copy of the Philippines Policies and
Guidelines in Special Education.
Projected Annual Review Date:_04/30/2017
Most Recent Evaluation Date: 05/01/2015_
Projected Re-evaluation Date: _05/01/2019
Primary Disability: Intellectual
Disability (ID)
 EXIT INFORMATION
Exit Date: MARCH 2028 (Age out)
Exit Category: ___ Returned to General Education ___ Graduated with Philippine
Elementary/High School Diploma _X__ Received Philippine Elem/High School Program
Completion ___ Reached Age Required Completion ___ Deceased ___ Moved, known to
be continuing ___ Dropped Out ___ Special Case ___ Parent revokes consent for
services

IEP TEAM PARTICIPANTS

IEP CASE MANAGER: Robi Imbo Principal/Designee: Stella Marie Cruz
IEP Chair Christel Ortega General Educator: Gina Amistad
Social Worker: RUBINA DURAN Others _______________
Parent/Guardian Kate Holmes Special Educator: Robi Imbo
Speech/Language Pathologist: JUSTINE LIBBY Ocupational Therapist: Daciel Diputado
Guidance Counsellor: LORELA MAHIPOS Student: Tom Cruise
Others: Isidro B. Villaflor (Parent Advocate)

INITIAL EVALUATION ELIGIBILITY DATA (Only required for student’s initial evaluation to determine
eligibility)
Identify area(s) impacted by the student’s suspected disability:

Based on record review (05/01/2017) and discussion, the IEP Team has determined that Tom is
eligible for special instruction in Reading, Mathematics, Written Language, and Speech / Language
skills.

Discussion to support decision:

Based on record review (05/01/2017), formal and informal assessment and discussion, the IEP
Team has agreed that there is adequate data available to determine Tom’s eligibility for Special
Education services under the disability of Intellectual Disability. Special Education Programs
should be initiated.

Tom’s Intellectual Disability continues to have an adverse impact on his ability to access the
general curriculum without support. His present level of performance falls under below the
age/grade level when compared to his peers in Reading, Mathematics, and Written Language.
Tom requires picture cues in all his daily classroom instruction. Overall, Tom needs Mother
Tongue Based (MTB) as medium of instruction in all his classes. He also needs structured
activities that will emphasize picture schedule, mini tasks, routine, and procedures. The
placement is in a self-contained classroom for the Intellectual Disability. Tom lacks the necessary
progress in the general education classroom as reflected in the results of the assessments. Goals
and objectives are selected and aligned to Tom’s identified needs.

Initial Eligibility (Student Age 5-25)

Child is eligible for Grade I Special Education and related services through an IEP. Yes
Indicate primary disability : INTELLECTUAL DISABILITY

Cognitive ( specify): None

Sensory (specify): None
Communication (Specify) Tom has difficulty in expressing himself resulting from sub average
intellectual functioning as well as sub average adaptive behavior skills.

Document basis for decision(s):

Based on the medical records presented by the parent, Tom has Down Syndrome (DS). The IEP
team agree that Tom will be placed in Special Education Program. He will attend classes in self –
contained class within the Special Education that will provide instructional accommodations and
supports, supplementary aids/services known as LRE-F (Private School Placement). Tom is pursuing
an elementary certificate of completion. Despite classroom intervention and support, Tom requires
speech and language services, individualized and differentiated instruction to meet his needs.

Overall Tom needs picture cues to address his educational needs. Due to Tom’s deficits in cognitive
abilities, inability to receive and express verbal language, and delays/deficits in Reading
Comprehension, Math and Written Language, Tom needs picture cues in all daily activities. He has
problems in spelling and comprehending written texts. He also has limited vocabulary. His
expressive and receptive communication abilities are limited compared with pupils of his age group
that limits his full participation in the general education environment with the use of supplementary
aids and services. Tom’s Special Education Services will be provided outside the general education
classroom setting in a LRE-F (Private Placement).

The Special Education services will provide accommodations, supplemental aids/services and
instructional strategies to allow Tom access the curriculum. His daily assignments will be adjusted as
needed. Tom will participate in selected academic, non-academic and extracurricular activities with
his peers without disabilities.

PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE (PLAAFP)

What is the parental input regarding the student’s educational program?

Ms. Katie Holmes, Mother of Tom indicated in the IEP Meeting (05/01/2017) that she has expressed
satisfaction with Tom’s achievement in school. He has communicated concerns with regards to the
expressive language of his son. He is much interested to see him talk with his parents, siblings, peers, and
classmates when exposed to daily conversation. His Mother also indicated that Tom’s ability to understand
daily conversations seems to be different from his siblings. He cannot respond to one step instruction. He
needs prompt when doing tasks related to home chores. Mr. Gallardo (Tom’s Father) indicated that he has
concerns with his behavior. In many cases, Tom shows inappropriate behavior as shown in everyday
performance of tasks at home. He throws himself down when basic needs such as food, clothing, and
recreation are not given at an appropriate time and day. Both parents indicated that they wanted Tom to be
promoted to Grade I Tom ring that he has been in Preschool for 3 years in a row.

What are the student’s strengths, interest areas, significant personal attributes, and personal
accomplishments?

Tom’s strength is identified in areas such as dancing. He is interested arcade gaes and other online games.
He is a jolly good fellow and generous. During his Kinder years, he was awarded gold medal in 10 meter run
during the Special Olypics. He also has the ability to play bowling and swimming. He won silver and bronze
medals respectively in an invitational games for children with special needs.
How does the student’s disability affect his/her involvement in the general education curriculum?

Tom is a child with intellectual disability. This condition associated with inability to express ideas as shown in
expressive and receptive skills has an adverse effect on his involvement in the general education curriculum
due to delays in Reading, Mathematics, and Written Language. Tom exhibits difficulty in learning the lessons
and display poor attention skills.

For preschool age children, how does the disability affect participation in appropriate activities?

N/A
Communication (required)
Does the student have special communication needs? YES NO (If yes, describe the specific needs.)

Tom needs directed sentence prompts in facilitating communication.

ASSISTIVE TECHNOLOGY (AT) (REQUIRED)

Consider AT device(s) and service(s) that are She student needs an AT service(s)
needed to increase, maintain or improve If yes, AT service(s) will be addressed through:
functional capabilities of a student with a _____ Supplementary Aids, Services, Program
disability Modifications, and Supports
The student needs an AT device(s) _____ Related Services Instructional and Testing
Accommodations
If yes, AT device(s) will be addressed through:
___ Supplementary Aids, Services, Program
Modifications, and Supports
____ Instructional and Testing Accommodations
Document Basis for decision:

Based on review, progress reports, teacher’s observation, assessment data, disability, placement,
and team discussion, the team determined that Tom will not be provided AT service at this time.

SERVICE FOR STUDENTS WHO ARE INTELLECTUAL DISABILITY OR HEARING IMPAIRED

In the case of a student who is Intellectual Disability or hearing impaired, consider language and
communication needs, opportunities for direct communications, academic level, and full range of
needs, including direct instruction in she student’s language and communication mode.

Were parents provided information regarding Philippines Schools for the Intellectual Disability? YES
NO
Document basis for decision(s):

Based on review, progress reports, teacher’s observation, assessment data, disability,

placement, and team discussion, the team determined that Tom will attend self-contained class for
children with Intellectual Disability (ID).

INSTRUCTIONAL AND TESTING ACCOMMODATIONS

1. PRESENTATION ACCOMMODATIONS: Conditions for Use in
Instruction and Assessment
Auditory Presentation Accommodations
1-G: Human Reader or Audio Recording of Selected Sections of Test
Multi-Sensory Presentation Accommodations
1-L: Text to Speech Software for Verbatim Reading of Entire Test
1-N: Screen Reading Software
1-O: Visual Cues
Other Presentation Accommodations
Materials or Devices Used to Solve or Organize Responses Conditions for Use in
Instruction and Assessment
2-H: Monitor Test Response
2-K: Spelling and Grammar Devices*
2-L: Visual Organizer I, A5
2-M: Graphic Organizer
2-N: Computer Access Tools/Devices/Software*
Other Response Accommodations
2-P: Unique
Document basis for decision
Based on review, progress reports, teacher’s observation, assessment
data, disability, placement, and team discussion, the team
determined that Tom will access the above accommodation as the
need arises.

Provide specific description stating the type of accommodation and

how the accommodation will be administered.

Tom will access the above accommodation in LRE-F otherwise known

as Private schools Placement.
INSTRUCTIONAL AND TESTING ACCOMMODATIONS

3. TIMING AND SCSHEDULING ACCOMMODATIONS:

3-A: Extended Time
3-B: Multiple or Frequent Breaks
Other Timing and Scheduling Accommodations
3-E: Unique
Document basis for decision:

Based on review, progress reports, teacher’s observation, assessment

data, disability, placement, and team discussion, the team
determined that Tom will access the above accommodation as the
need arises.
4. SETTING ACCOMMODATIONS:
4-A: Reduce Distractions to she Student
4-B: Reduce Distractions to Other Students
Other Setting Accommodations
4-E: Unique
Document basis for decision:
Based on review, progress reports, teacher’s observation, assessment
data, disability, placement, and team discussion, the team
determined that Tom will access the above accommodation as the
need arises.

Instructional and testing accommodations were considered and no instructional and testing
accommodations are required at this time. Document basis for decision:

Based on review, progress reports, teacher’s observation, assessment data, disability, placement,
and team discussion, the team determined that will be provided with accommodations on a needs
basis only.
SUPPLEMENTARY AIDS, SERVICES, PROGRAM MODIFICATIONS AND SUPPORTS
Instructional Support(s)
Nature of Service Frequency Begin Date End Date Provider(s) = Primary, = Other
Begin
_x_ Allow use of Anticipated 04/30/201 05/01/20 _x_ Teacher of the Intellectual
manipulative Frequency 6 17 Disability
_x_ Allow use of _x Daily
organizational
aids
x Check for
understanding
__Frequent
and/or immediate
feedback
_x_ Monitor
independent
work
___ Repitition of
instructions
Clarify location and manner:
The above instructional supports will be implemented in the LRE-F (Private Placement) as the need
arises.
SUPPLEMENTARY AIDS, SERVICES, PROGRAM MODIFICATIONS AND SUPPORTS
Program Modification(s)
Nature of Service Frequency Begin Date End Date Provider(s) =
Primary, = Other
_x_ Break down Anticipated 04/30/2016 05/01/2017 X Teacher of the
assignments into Frequency Intellectual
smaller units _x Daily Disability
_x_ Chunking of
text(s)
_x_ Use pictures
to support
reading passages,
whenever
possible

Clarify location and manner:

She above supplementary aids, services, program modifications, etc will be implemented in the
LRE-F (Private Placement) as the need arises.
SUPPLEMENTARY AIDS, SERVICES, PROGRAM MODIFICATIONS AND SUPPORTS
Social/Behavior Support(s)
Nature of Service Frequency Begin Date End Date Provider(s) =
Primary, = Other
_x_ Adult support Anticipated 04/30/2016 05/01/2017 __Psychologist
__Anger Frequency _x_ Teacher of
management _x_ Daily the Intellectual
training Disability
__Crisis __ Instructional
intervention Assistant
_x_ Frequent
reminder of rules
__Home-school
communication
system
__Implementatio
n of behavior
contract
_x Reinforce
positive behavior
through non-
verbal/verbal
communication
Social skills
training Strategies
to initiate and
sustain attention
_x_ Use of
positive/concrete
reinforces

Clarify location and manner:

Based on review, progress reports, teacher’s observation, assessment data, disability, placement,
and team discussion, the team determined that Tom will access the above accommodation as the
need arises.
SUPPLEMENTARY AIDS, SERVICES, PROGRAM MODIFICATIONS AND SUPPORTS
Physical/Environmental Support(s)
Nature of Service Frequency Begin Date End Date Provider(s) =
Primary, = Other
None None None None None
SUPPLEMENTARY AIDS, SERVICES, PROGRAM MODIFICATIONS AND SUPPORTS
School Personnel/Parental Support(s)
Nature of Service Frequency Begin Date End Date Provider(s) =
Primary, = Other
__Coordination of Anticipated 04/30/2016 05/01/2017 __Psychologist
support services Frequency __ Teacher of the
for crisis __Daily Intellectual
prevention and Disability
interventions __ Instructional
__Psychologist Assistant
consult
__School health
consult

Agency Linkage Student Referred Agency Representative Anticipated Services for

to Invited to the Meeting Transition
Yes NO Yes NO Yes NO
DSWD x x x
DOLE
LGU
NGO
other

Areas Assessed:

Psycho – Educational

Behavior

• Based on daily observation, Tom could not follow simple instruction in the classroom. He
would just look at the teacher even if he is instructed. He needs gestures and full physical
prompts to allow him to respond and follow instruction. Tom cannot stay long in his seat and
he loves to roam around inside the classroom. Every time an instruction is given in an
outdoor activity, Tom cannot follow it. Instructions such as walk slowly, stay calm, and stop
served as prompt in providing him with attending skills. He needs model prompt to allow
him process information and follow instructions.

Goal: By May 2016, Tom will follow simple instructions with prompts 1 time with 80% accuracy.

Objective 1: Given single instruction, Tom will follow the given instruction with prompts 1 time with
80% accuracy.
Objective 2: Given two instructions, Tom will follow the given instructions with prompts 1 time with
80% accuracy.
Objective 3: Given three instructions, Tom will follow the given instructions with prompts 1 time
with 80% accuracy.

Math Calculation:

Based on Brigance Basic Inventory of Basic Skills conducted on March 20,2015, Tom is on
kindergarten level in Math Calculation. He can add mathematical problems with picture. He needs
to add mathematical problems without pictures.

Goal: By May 2016, Tom will add mathematical problem without pictures with 80% accuracy over
three trials as measured by informal assessment and classroom performance.

Objective 1: Given one digit number, Tom will add numbers using sets of counters with prompts 1
time with 80% accuracy
Objective 2: Given one digit numbers, Tom will add numbers using continues counting with prompts
1 time with 80% accuracy.
Objective 3: Given one digit numbers, Tom will add numbers using finger Math with prompts 1 time
with 80% accuracy.

Reading Comprehension:

Based on Brigance Basic Inventory of Basic Skills conducted on March 20, 2015, Tom is on
kindergarten level in reading comprehension. he can read three letter words listed in “family words”
with picture cues. She needs to read words without pictures.

Goal: By May 2016, Tom will read family words with three letters without pictures with 80%
accuracy over three trials as measured by informal assessment and classroom performance.

Objective 1: Given flashcard, Tom will read the three letters word with pictures.
Objective 2: Given configuration boxes, Tom will read she three letter-s word.
Objective 3: Given Dolch Words, Tom will read letters word without pictures.

Written Language

Based on Brigance Basic Inventory of Basic Skills conducted on March 20, 2015, Tom is on
kindergarten level in writing language. She can write straight lines, slanting lines and rounded
strokes. She needs to write uppercase and lowercase letters of the alphabet.

Goal: By May 2016, Tom will write uppercase and lowercase letters of the alphabet with 80%
accuracy over three trials as measured by informal assessment and classroom performance.
Objective 1: Given tracing workSheet, Tom will write uppercase and lowercase letters of the
alphabet.
Objective 2: Given correct stroke, Tom will write uppercase and lowercase letters of the alphabet.
Objective 3: Given writing prompts, Tom will write the uppercase and lowercase letters of the
alphabet.

Summer School goal? YES NO

Objective 1:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Objective 2:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Objective 3:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Objective 4:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Progress Toward Goal

Progress Report 1
Date_______

Progress Code:
___ Achieved
___ Making sufficient progress to meet goal
___Newly introduced skill; progress not measurable at this time
___ Not making sufficient progress to meet the goal (IEP team needs to meet to address insufficient
progress)
___Not yet introduced

Description of Progress:

Tom has the ability to add single digit by single digit numbers without regrouping with prompts. He
needs to add numbers independently.

Progress Toward Goal

Progress Report 2
Date_______

Progress Code:
___ Achieved Making sufficient progress to meet goal
___Newly introduced skill; progress not measurable at this time
___ Not making sufficient progress to meet the goal
___Not yet introduced (IEP team needs to meet to address insufficient progress)

Description of Progress:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Progress Toward Goal

Progress Report 3
Date_______

Progress Code:
___ Achieved Making sufficient progress to meet goal
___Newly introduced skill; progress not measurable at this time
___ Not making sufficient progress to meet the goal
___Not yet introduced (IEP team needs to meet to address insufficient progress)

Description of Progress:
_________________________________________________________________________________
____________________________ ____________
Progress Toward Goal
Progress Report 4
Date_______

Progress Code:
___ Achieved
___ Making sufficient progress to meet goal
___Newly introduced skill; progress not measurable at this time
___ Not making sufficient progress to meet the goal
___Not yet introduced (IEP team needs to meet to address insufficient progress)

Description of Progress:
_________________________________________________________________________________
____________________________ ____________

How will the parent be notified of the student’s progress toward the IEP goals?
_________________________________________________________________________________
_______
How often?
WEEKLY
BI-WEEKLY
MONTHLY
INTERIM
QUARTERLY
END OF MARKING PERIOD
OTHER ____________________

SERVICES
SPECIAL EDUCATION SERVICES
Service Location Service Description Begin End Provider(s) = Summary
Nature Date Date Primary, = Other of Service

Classroom In Num Le Freq 04/30/ 05/01/ __Orientation & Total

Instruction General ber of ngt uenc 2016 2017 Mobility Specialist service
(Identifying Educatio Sessi h y __ Audiologist P time:
the number n ons 1 of Daily Speech/Language weekly
of sessions 234 Ti Wee Pathologist monthly
for Outside 56 me kly __ Psychologist yearly
Classroom General Other __ Mon __ Teacher of the __40__Hrs.
Instruction Educatio __ __ thly hearing Impaired ____Min.
is optional) n Ho Yearl __ IEP Team
urs y __ Teacher of the
Physical __ Only Visually Impaired
Education __ once __ Interpreter
Mi Quar __ Occupational
Speech/Lan nu terly Therapist
guage tes Semi __ Instructional
Therapy - Assistant
annu __ Pupil Personnel
Travel a Worker
Training __ Physical
Therapist
__ Physical
Education Teacher
__ Home-Based
Teacher
__ Rehabilitation
Services Staff
__ Guidance
Counsellor
__ General
Education Teacher
__ School Social
Worker P Career &
Technology
Teacher
__ Recreational
Therapist
__ Department of
Social Services
(DSS) __ Certified
Occupational
__ DOH
__ DSWD
__ Physical
Therapy
__ DOLE
Other
Agency_________
_______________
___ __
Speech/Language
__Special
Education
__Classroom
Teacher
__Other Service
Provider
_______________
_
__Therapeutic
Behavioral Aide
SERVICES
RELATED SERVICES
Service Location Service Description Begin End Provider(s) = Summary
Nature Date Date Primary, = Other of Service

Audiological In Num Le Freq MM•D MM•D __Orientation & Total

Services General ber of ngt uenc D YYYY D Mobility Specialist service
Educatio Sessi h y YYYY __ Audiologist P time:
Psychologic n ons 1 of Daily Speech/Language weekly
al Services 234 Ti Wee Pathologist monthly
OutTom 56 me kly __ Psychologist yearly
Occupation e Other __ Mon __ Teacher of the ____Hrs.
al Therapy General __ __ thly Hearing Impaired ____Min.
Educatio Ho Yearl __ IEP Team
Physical n urs y __ Teacher of the
Therapy __ Only Visually Impaired
__ once __ Interpreter
Recreation Mi Quar __ Occupational
nu terly Therapist
Early tes Semi __ Instructional
Identificatio - Assistant
n annu __ Pupil Personnel
&Assessme a Worker
nt __ Physical
Therapist
Counseling __ Physical
Services Education Teacher
__ Home-Based
School Teacher
Shealth __ Rehabilitation
Services Services Staff
__ Guidance
Social Work Counsellor
Services __ General
Education Teacher
Parent __ School Social
Counseling Worker P Career &
& Training Technology
Teacher
Rehabilitati __ Recreational
ve Therapist
Counseling __ Department of
Social Services
Orientation (DSS) __ Certified
& Mobility Occupational
Training __ DOH
Services __ DSWD
__ Physical
Assistive Therapy
Technology __ DOLE
Services Other
Agency_________
Medical _______________
Services ___ __
(Diagnostic Speech/Language
& __Special
Evaluation) Education
__Classroom
Other Teacher
Thisapies __Other Service
__________ Provider
____ _______________
Interpreting _
Services __Therapeutic
Behavioral Aide
Speech/Lan
guage
Therapy

Nursing
Services
SERVICES
CAREER AND TECHNOLOGY EDUCATION SERVICES
Service Location Service Description Begin End Provider(s) = Summary
Nature Date Date Primary, = Other of Service

Career and In Num Le Freq MM•D MM•D __Orientation & Total

Technology General ber of ngt uenc D YYYY D Mobility Specialist service
Education Educatio Sessi h y YYYY __ Audiologist P time:
n ons 1 of Daily Speech/Language weekly
Program 234 Ti Wee Pathologist monthly
w/Support OutTom 56 me kly __ Psychologist yearly
Services e Other __ Mon __ Teacher of the ____Hrs.
General __ __ thly Hearing Impaired ____Min.
Vocational Educatio Ho Yearl __ IEP Team
Evaluation n urs y __ Teacher of the
__ Only Visually Impaired
Special __ once __ Interpreter
Education Mi Quar __ Occupational
Program nu terly Therapist
with Pre- tes Semi __ Instructional
Vocation - Assistant
Objectives annu __ Pupil Personnel
a Worker
__ Physical
Therapist
__ Physical
Education Teacher
__ Home-Based
Teacher
__ Rehabilitation
Services Staff
 __ Guidance
Counsellor
__ General
Education Teacher
__ School Social
Worker P Career &
Technology
Teacher
__ Recreational
Therapist
__ Department of
Social Services
(DSS) __ Certified
Occupational
__ DOH
__ DSWD
__ Physical
Therapy
__ DOLE
Other
Agency_________
_______________
___ __
Speech/Language
__Special
Education
__Classroom
Teacher
__Other Service
Provider
_______________
_
__Therapeutic
Behavioral Aide
LEAST RESTRICTIVE ENVIRONMENT (LRE) DECISION MAKING & PLACEMENT SUMMARY
A student with a disability is not removed from general education in an age-appropriate
instructional setting solely because of needed modifications to the general curriculum.

AUTHORIZATION(S)
CONSENT FOR INITIATION OF SERVICES (initial IEP only)
I have received a copy of the Evaluation Report informing me in writing of the reasons for this
action. The special education and related services will be provided as described in the IEP. I
understand that the IEP will be reviewed periodically but not less than annually. I understand that
records will not be released without my signed and written consent. I understand that my consent is
voluntary and that I may revoke consent at any time. Should I revoke consent it is not retroactive. If
I revoke consent, in writing, for my child to receive special education services after my child is
initially provided special education and related services, the public agency is not required to amend
my child’s education records to remove any references to my child’s receipt of special education
and related services because of my revocation of consent. I understand that the public agency will
submit information that will be used for the special services information system. This system will be
used by the DepEd and Other Public Agencies, as appropriate, to enable funding of programs and to
assure my child’s rights to any needed assessment. I have been informed of the determination(s) of
the IEP team in my native language or Other mode of communication. I have been informed of my
rights. I consent to the initiation of special education and related services for my child, as specified
in my child’s IEP.

Parent Signature:
_____________________________________________________________________

Date: ___________________________________________________
__________________