Preschool Request for Consent to Evaluate
Child’s Name:
School District:
Date of Birth:
1. Check whether or not you give consent to have your child evaluated.
2. If you DO give consent, select one of the evaluation sites below, sign and return this form
to the Committee on Special Education (CPSE) Chairperson as soon as possible.
I DO NOT give my consent to have my child evaluated.
I DO give consent to have my child evaluated AND
Give consent for my child’s most recent physical and immunization records to be
released to the site selected below.
My child’s Physician’s name is
The checked site below is my choice for the evaluation.
Adirondack ARC
Children’s Corner
Tupper Lake, NY
Adirondack Helping Hands
16 Degrandpre Way Suite 500
Plattsburgh, NY 12901
Children’s Development Group
1717 Front Street
Keeseville, NY 12944
Mountain Lakes Services
Port Henry, NY
*Home Based: 8am – 6pm
Newmeadow Saratoga School
100 Saratoga Village Blvd, Suite 35
Malta, NY 12020
North Country Kids
22 New York Road
Plattsburgh, NY 12903
Signature of Parent/Guardian
Pc: District Chairperson
Municipality Revised August 2018
Adirondack Enrichment
13 Locust St
Glens Falls, NY 12801