Fillable VERIFICATION OF RECEIPT OF THE EARLY START DUE (Westside Regional Center)

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VERIFICATION OF RECEIPT OF THE EARLY START DUE (Westside Regional Center)

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VERIFICATION OF RECEIPT OF THE EARLY START DUE PROCESS
AND FAIR HEARING PROCEDURE AND THE PARENTS RIGHTS
AND RESPONSIBILITIES IN THE EARLY START PROGRAM
I have received a copy of the Early Start Due Process and Fair Hearing Procedure.
_______________________________________ ___________________
Consumer, Parents, Conservator or Guardian Date
I have received a copy of the “Parents Rights and Responsibilities in the Early Start Program.”
_______________________________________ ___________________
Consumer, Parents, Conservator or Guardian Date
Consumer Name:____________________________________
DOB:______________________________________________
UCI Number:________________________________________
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VERIFICATION OF RECEIPT OF THE EARLY START DUE (Westside Regional Center)

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Completed 7 February 2021

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