Education Services Plan Request

Education Services Plan Request

Request Date:

Student Information

Parent / Guardian or Adult Student Contact

Request Details

Type of request (select all that apply):

Academic tutoring
Learning accommodations (e.g. extended time, modified format)
Behavioral support plan
Special education evaluation (eligibility determination)
504 accommodations
Other — specify:

Medical / Diagnostic Information (if applicable)

Supporting documentation: Supporting documents attached

Authorization to Obtain and Share Records

By checking items below and signing this form, I authorize the school and its authorized staff to obtain, review, and share the indicated records as necessary to evaluate and implement requested services. I understand records will be used solely for educational planning and maintained with confidentiality consistent with school policy.

Academic records (grades, transcripts, attendance)
Medical records relevant to educational needs
Psychological, neuropsychological, or functional assessments
Other records — specify:

Administrative Acknowledgment and Process

Submission of this request initiates a formal review. The school will acknowledge receipt in writing and will review existing records and supports. Additional assessment or screening may be scheduled as needed to determine eligibility for specialized services.

The school will attempt to complete initial review and provide a written response within a reasonable administrative timeframe following receipt of required documentation. Interim accommodations may be provided when immediate educational risk or need is identified.

Information provided on this form will be maintained in the student’s educational record. The school will limit disclosure to staff with a legitimate educational interest and to outside professionals as authorized above.

Certification and Signature

I certify that I am the parent, legal guardian, or adult student legally authorized to make educational decisions for the student named above. The statements on this form are true and complete to the best of my knowledge. I understand that knowingly providing false information may result in denial of services and other consequences under school policy. By signing below I consent to the collection and review of records and to any routine evaluations necessary to determine eligibility and appropriate services. This authorization remains in effect for the duration of the review unless revoked in writing.

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