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________________________________________ ____________________
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Placement Statement
Parental Consent For Initial Educational Placement
I have been fully informed of all information relevant to the proposed program placement.
for the placement of my child in the special education placement/service based on the IEP, and AGREE WITH
it’s content, with the understanding that the need for this placement will be reviewed at least once annually in
relation to my child’s educational needs.
Student Name___________________________________ DOB___________ School____________________
Grade _____ Categorical Eligibility_____________________________________________________________
Parent/Guardian Signature Date
Education Program and DO NOT AGREE with the educational placement. I also understand my parental
rights.
Parent/Guardian Signature Date
Date of IEP initiation will be _______________
Continued Educational Placement
Procedural Safeguards Received
Yes No Parent/Guardian Initials Date Mailed
______ ___________________________
Please sign the appropriate statement:
I, as parent or guardian, have had the opportunity to participate in the development of this IEP, give the consent
I have had the opportunity to participate in the development of this IEP and I DISAGREE with the Individual
