Today's Date:   

Parent's Name: 

Contact Phone: 

Contact Email:  

Child's Name:  

Child's Current School:  

Current Grade Level:   Pre-K 1 2 3 4 5 6 7 8 9 10 11 12 College

School District:  

Does Child have an IEP in place:  Yes   No

If NO;

Has an evaluation been completed by the school district:  Yes   No   In process

Has an evaluation been requested, in writing, by parents:   Yes   No

Child's Diagnosis (outside diagnosis):  

IEP Classifications (SLD, ASD,  EMH, etc...):  

Current Issues needing assistance with:  

Authorization:

Special Students of Hernando, at times, feels it is important to gather information from the Hernando County School District to best serve parents and their children. 

Do you authorize Special Students of Hernando to obtain information regarding your child's educational records, if necessary.

Yes, I authorize Special Students of Hernando to obtain information regarding my child from the Hernando County School District.

No, I do not authorize Special Students of Hernando to obtain information about my child from the Hernando County School District

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