a 4219712008 103531 2ISR2SSERA January 13, 2015 Angal Name of Studect oa ASD ‘SASID Date Consent for Special Educatton Evaluation ‘Wa request your consent because: This is an intial evatuation and wil be used to determine whether your child is a child with a disabilty and to determine sspetial education needs, 200.500} Parental Options: [U1 give my consent for the evaluation. | understand my consent is voluntary and may be revoked for any evaluation or reevaluation that has not yet been conducted, 200.9(a)(b.(c).(1) and 2) frefuse consent for the evaluation. fetes Parent Bi E Date Parent Signature Bae For intial evaluations, a copy of the Notice of Procedural Safeguards has been given to the parents, Consent To Evaluate ‘Consent Granted: Date Response Recelved: Prior Notice & Consent for Evaluation ‘Summit School District Page 3 of 3