Mother's Name:

Father's Name:

Telephone:

Best time to reach you:

Your Email:

Student's Name:

Student's Gender:

Student's date of birth:

Student's current grade:

Your legal relationship to student (ie birth parent, adoptive parent, grandparent, etc):

If yes, date of eligibility and current category?

If no, what is the students disability?

DOE home school of student:

Is student attending a DOE charter school, if so identify school:

Is student attending on a geographic exception, if so identify school:

Is student enrolled in a private school, if so identify school:

What is the current problem(s) you are experiencing with the DOE or the students IEP?

Has the student ever been suspended or placed on home tutoring?
If so, give dates and reasons:

Have you filed a due process request in the past? If so, result?