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SAMPLE RELATED SERVICE EVALUATION REQUEST
YOUR
NAME
YOUR ADDRESS
YOUR PHONE NUMBER
DATE
PRINCIPAL
CHILD’S SCHOOL
ADDRESSDear (Principal Name):
I am the parent of (child’s name), whose date of birth is (child’s birth date),
and who is a student in the grade.
I am requesting that the__________________ School conduct an Evaluation for
(list specific related service request) on my child for the following reasons:
(State the reason for your request!)
I am also giving my permission for the____________________ School to conduct the
(list specific service request) Evaluation in order to determine if my child
needs special education and if so what programs and services are needed.
I am aware of the state prescribed 60 school day time line to conduct and
provide me with a copy of the evaluation.
Should you have any questions with this request, please contact me at the above
address and/or phone number.
Thank you.
Sincerely,
(YOUR NAME)
cc: Regional Director of Special Education
Regional Case Manager
Advocate
(List anyone else you are giving a copy of this letter to.) |