______________
Date
To the Parent(s)/Guardian of _________________________________________________:
As a result of our recent ___Student Focus Team meeting ___ Eligibility meeting
___ Student Plan meeting (AP/IEP/504) or conversation, I am providing you a copy of the following document
(applicable to items marked):
____ Prior Written Notice
____ Request for Evaluation
____ Consent For Assessment as Part of a Reevaluation
____ Consent for Initial Provision of Section 504 and Related Services
____ Consent for Release of Information - _____________________________________
____ Authorization for DOE to Receive Information - _____________________________
____ Evaluation Summary Report ____________________________________________
____ Section 504 Eligibility Determination _____________________________________
____ Action Plan (AP)
____ Individualized Education Plan (IEP)
____ Section 504 Modification Plan (MP)
____ Behavior Support Plan
____ Provided to parent at Initial/Annual MP Plan: The Procedural Safeguards Notice for
Parents and Students Under The Individuals With Disabilities Education Act and
Hawaii Law and regulations, March 2017, RS 16-1308.
____ Provided to parent at Annual MP meeting: Rights of Parents and Students Under
Section 504, Subpart D and Hawaii Law and Regulations, RS17-1183, April 2017
(Rev. of RS 14-1409)
____ Other - _____________________________________________________________
____ Next Meeting: _______________________________________________________
Please call me at 305- 1600 should you have any questions.
Sincerely,
___________________
Student Services Coordinator
***** Please return this acknowledgement to your child’s Care Coordinator*****
I have received a copy of the items marked above.
_________________________________
_________________
Parent/Guardian Signature
Date