Pupil Services Department
27200 Hilliard BLVD
Westlake, OH 44145
440.250.1264 or 440.835.6309
440.835.6786 fax
Signatures
Student Name:
Birth Date:
Acknowledgement of Notification regarding Medicaid School Based Services
Parent/Guardian Initials______
I have been notified that Westlake City Schools will seek reimbursement from Medicaid for
School Based Services rendered on behalf of my child for all services listed on the IEP.
Acknowledgement of ASP and JPSN Scholarship Opportunities
Parent/Guardian Initials______
Acknowledgement of Notification of the requirement to schedule an eye exam
appoint for my child within 90 days.
Parent/Guardian Initials______
I additionally understand that I need to return the eye exam report to the school district.
Parent/Guardian Signature: ______________________________
Routing:
Date: ___________________
Pupil Services Department
WE EDUCATE FOR EXCELLENCE…
Empowering all students to achieve their educational goals, to direct their lives, and to
contribute to society