Page 1 of 17

MARIN CO. SELPA

INDIVIDUALIZED EDUCATION PROGRAM (IEP) - INFORMATION / ELIGIBILITY
Student Name Arreola-Muro, Alexis

Date of Birth 2/9/2004

IEP Date: 2/3/2015

Last Annual IEP 2/3/2015

Next Annual IEP 2/3/2016

Original SpEd Entry Date 2/15/2011

Last Eval 2/4/2014

Next Eval 2/4/2017

Purpose of Meeting

Initial

Annual

Triennial

Transition

Pre-Expulsion

Interim

Other

Age 10

Gender

Male

Grade Fifth grade

Migrant

Yes

EL

Redesignated

Interpreter

SSN#:

SSID# 6195618404

Yes

No

Student ID 32088
Residency

Female
No

Native Language Spanish

Yes

No

10 Parent or Legal guardian

Parent/Guardian
Home Address
City
State, Zip

Esther / Jorge Muro

579 Tanbark Terrace
San Rafael
CA , 94903

Home Phone
Work Phone
Cell Phone
Email Address

415-250-0587
415-717-1129

Parent/Guardian
Home Address
City
State, Zip
CA ,

Home Phone
Work Phone
Cell Phone
Email Address

District of Residence Dixie Elementary

Residence School Vallecito Elementary

Ethnicity: 500 Hispanic

Race 1. 700 White Race 2.

Race 3.

INDICATE DISABILITY/IES Note: For initial and triennial IEPs, assessment must be done and discussed by IEP Team before
determining eligibility.
Primary Other Health Impairment (OHI) Secondary 200 None * Low Incidence Disability
Not Eligible for Special Education

Exiting from Sp. ED. (returned to reg. ed/no longer eligible)

Describe how student's disability affects involvement and progress in general curriculum(or for preschoolers,
participation in appropriate activities) Alexis requires specialized academic instruction to access general education curriculum
because of a diagnosis of ADHD which significantly impacts his academic performance.
FOR INITIAL PLACEMENTS ONLY
Has the student received IDEA Coordinated Early Intervening Services (CEIS)
using 15% of IDEA funding in the past two years?
Date of Initial Referral for Special Education Services
Person Initiating the Referral for Special Education service
Date District Received Parent Consent:
Date of Initial Meeting to Determine Eligibility

Yes

No

11/22/2010
20 Teacher
12/14/2010
02/15/2011

Page 2 of 17
MARIN CO. SELPA
PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Student Name Arreola-Muro, Alexis

Date of Birth 2/9/2004

IEP Date: 2/3/2015

Strengths/Preferences/Interests
Alexis is a friendly boy with a good sense of humor. He is artistic, athletic and can be very energized about learning when
motivated to focus on a task.
Concerns of parent relevant to educational progress
Questions and concerns will be recorded on the notes page.

SBAC (Scores not available from 2014)

English/Language Arts

Adv.

Proficient

Basic

Below Basic

Far Below Basic

Math

Adv.

Proficient

Basic

Below Basic

Far Below Basic

CA Standards Test
Science
Adv.

Proficient

Basic

Below Basic

Far Below Basic

CMA
Science

Adv.

Proficient

Basic

Below Basic

Far Below Basic

CAPA
English/Language Arts

Adv.

Proficient

Basic

Below Basic

Far Below Basic

Math

Adv.

Proficient

Basic

Below Basic

Far Below Basic

Science

Adv.

Proficient

Basic

Below Basic

Far Below Basic

CELDT
Listening 563

Speaking 540

Reading 543

Writing 527

Physical Education Testing (grades 5, 7 & 9): Alexis will participate in general education P.E.
Other Assessment Data (e.g., curriculum assessment, other district assessment, etc.) Lexile score from September 2014 is
435
Hearing Date:( 8/28/2014 )

Pass

Fail

Other

Vision Date: ( 8/28/2014 )

Pass

Fail

Other

Preacademic/Academic/Functional Skills
Alexis is a fifth grade student in Ms. Terry Colyers classroom. He is currently performing at grade level in math and below grade
level in reading comprehension and writing. Alexis is sweet and polite in the classroom. Math is a strength of his. Alexis can be
very energized about learning when motivated to focus on a task. Alexis can improve on his participation during class
discussions and seeking help when needed. Alexis has difficulty completing classwork and homework on time. He uses an
assignment notebook and has made progress with consistently filling it out daily. Alexis requires help organizing his school
materials. He has received support in this area through the use of separate, labeled, folders in his binder for each subject,
projects, and homework. The contents of his binder have also been reviewed and organized with Alexis in the resource room.
There are several classroom accommodations that are helpful to Alexis such as, preferential seating, directions given in a
variety of ways, frequent breaks, a peer buddy, extended time for completing tests and assignments, shortened assignments,
repeating information, checking for understanding, and using a cue for re-focusing.

Page 3 of 17
Alexis has worked on academic goals in the areas of reading comprehension and writing. He has met his goal in the area of
writing. When provided with a graphic organizer, Alexis is able to plan and write a multiple paragraph composition consistently.
Continued writing support will further help towards the improvement of Alexis's abilities, particularly in editing for punctuation,
capitalization, and correct word order. Although Alexis has made progress in the area of reading comprehension this year, he
has not met this goal. We will continue working on this area and focus on strategies he can use such as highlighting and taking
notes while reading in order to better understand the text.
Alexis will continue to benefit from specialized academic support in the areas of reading comprehension, writing and support
with organization.
Communication Development
Alexis' communication skills are age appropriate.
Gross/Fine Motor Development
Alexis' gross and fine motor skills are age appropriate.
Social Emotional/Behavioral
Alexis has many friends and gets along well with his peers.
Vocational
Alexis has age appropriate interests.
Adaptive/Daily Living Skills
Alexis has age appropriate daily living skills.
Health
Alexis is in good health. He takes Concerta for ADHD.
For student to receive educational benefit, goals will be written to address the following areas of need:
Alexis requires goals in the areas of reading comprehension, writing and organization.

Page 4 of 17
MARIN CO. SELPA
SPECIFIC LEARNING DISABILITY
TEAM DETERMINATION OF ELIGIBILITY
Student Name Arreola-Muro, Alexis
School Vallecito Elementary
Date 2/3/2015
I.

Date of Birth 2/9/2004

Initial Evaluation
3-Year Re-evaluation

IEP Date: 2/3/2015

VI.

Presence of Severe Discrepancy. (Select either A or B and then complete items II through IV.)
A. The IEP Team finds a severe discrepancy between measures of intellectual ability and one or more of the
following areas of achievement:
Oral Expression
Written Expression
Listening Comprehension
Mathematics Calculation
Basic Reading Skills
Mathematics Reasoning
Reading Comprehension
Reading Fluency
B. Standard measures do not reveal a severe discrepancy, but the IEP Team finds that a severe discrepancy
does exist based upon the additional documentation provided in the attached report. (Complete and attach
Specific Learning Disability Discrepancy documentation form)
The discrepancy identified in Item I. (above) is directly related to a processing disorder.
Yes No
Check appropriate area(s):
Sensory Motor Skills
Visual Processing
Auditory Processing
Attention
Cognitive Abilities,(including association, conceptualization and expression)
If any of the items below(A-G) are checked "Yes", the student may not be identified as having a specific learning
disability.
A. The discrepancy is due primarily to limited school experience or poor school attendance.
Yes No
B. The discrepancy is a result of environmental, cultural difference or economic disadvantage.
Yes No
C. The discrepancy is due primarily to intellectual disability or emotional disturbance.
Yes No
D. The discrepancy is due primarily to a visual, hearing, or motor disability.
Yes No
E. This discrepancy can be corrected through other regular or categorical services offered within the regular
Yes No
Instructional program.
F. The discrepancy is due to limited English proficiency.
Yes No
G. The discrepancy is due to lack of appropriate instruction in reading and math.
Yes No
The Student has a specific learning disability.
Yes No
Basis for determination of eligibility
Psycho educational Evaluation utilizing multiple measures. See attached psycho educational report.
Other (specify)
Relevant behavior related to academic functioning, noted during observation

VII.

See attached Psycho educational report.

Educationally relevant medical findings, if any (describe)

II.

III.

IV.
V.

I agree with the conclusions stated above:

/
School Psychologist / Date
/
Special Education Teacher / Date
/
LSH Specialist / Date
/
Parent / Guardian / Date

/
Special Ed. Admin / Designee / Date
/
General Education Teacher / Date
/
Reading Teacher / Date
/
Other / Date

My assessment of this student differs from the above report as follows: Statement (attach additional pages as necessary)
/
Signature and Title/Date

Page 5 of 17
Page 2
MARIN CO. SELPA
SPECIFIC LEARNING DISABILITY DISCREPANCY DOCUMENTATION REPORT
(INDIVIDUALIZED EDUCATION PROGRAM TEAM CERTIFICATION)
Student Name Arreola-Muro, Alexis

Date of Birth 2/9/2004

IEP Date: 2/3/2015

This form is to be completed and attached to the IEP Team Certification identification of Specific Learning Disability
Form in order to document the presence of a Specific Learning Disability in instances when the student does not exhibit
a severe discrepancy between ability and achievement as measured by standardized test. (Ed. Code Section 3030j
Paragraph C)
Statement of the area, the degree, and the basis and method used in determining the discrepancy:
1.

Data from assessment instruments (ability and achievement):

2.

Information provided by the parent:

3.

Information provided by the pupil's present teacher:

4.

Summary of the pupil's classroom performance:

a. Observations:
b. Work Samples:
c. Group Test Scores:

5.

Consideration of the pupil's age:

6.

Additional Relevant Information:

Page 6 of 17
MARIN CO. SELPA
ANNUAL GOALS AND OBJECTIVES

Student Name Arreola-Muro, Alexis

Area of Need: Academic Writing

Date of Birth 2/9/2004

IEP Date: 2/3/2015

Measurable Annual Goal# 1

Goal: By 2/3/16, following teacher-led pre-writing activities, Alexis will produce a correctly
indented multiple paragraph composition that includes an introductory paragraph with a topic
sentence, supporting paragraphs with facts/details/explanations, and a concluding paragraph
as well as rereading his writing to check for capitalization, punctuation and correct word order
with at least 80% accuracy in 2 of 3 trials as measured by student work samples.

Baseline: Given a graphic

organizer, Alexis is performing
at 80% accuracy. He continues
to require support in
Enables student to be involved/progress in general curriculum/state standard W.5.1,
organization and editing of his
W.5.2, W.5.3, W.5.4
writing. Without a graphic
organizer his performs at 5060% accuracy.
Addresses other educational needs resulting from the disability
Linguistically appropriate
Transition Goal:
Education/Training
Employment
Person(s) Responsible Classroom and RSP teachers

Independent Living

Progress Report 1: 3/21/2015

Summary of Progress Alexis continues to work on organization, focus, editing and motivation. He does not consistently give his
best effort.
Alexis has good ideas and is capable of producing quality work.
Comment
Progress Report 2: 6/11/2015
Summary of Progress
Comment
Progress Report 3: 12/5/2015
Summary of Progress
Comment
Annual Review Date: 2/3/2016
Goal Met
Yes No Comments:

Page 7 of 17
MARIN CO. SELPA
ANNUAL GOALS AND OBJECTIVES

Student Name Arreola-Muro, Alexis

Area of Need: Academic- Reading
Comprehension

Date of Birth 2/9/2004

IEP Date: 2/3/2015

Measurable Annual Goal# 2

Goal: By 02/03/16, given a story or drama at a 4th or 5th grade level, Alexis will
describe a character, setting, or event, and will draw on specific details in the text,
with 70% accuracy, in 2 of 3 trials as measured by student work samples.

Baseline: Alexis continues to complete 4th

grade comprehension assessments with
Enables student to be involved/progress in general curriculum/state
70% accuracy. He does well when asked to
standard RL5.1, RL5.10, RF5.4
recall facts and details from the text, but
struggles to consistently identify the main
idea and distinguish between fact and
Addresses other educational needs resulting from the disability
opinion.
Linguistically appropriate
Transition
Goal:
Education/Training
Employment
Person(s) Responsible Classroom and RSP teachers

Independent Living

Progress Report 1: 3/21/2015

Summary of Progress Alexis' effort can be very inconsistent depending on his motivation. In the past he has scored much
higher on this type of assessment. Alexis' most recent score was 3/12 on 4th/5th grade text.
Comment
Progress Report 2: 6/11/2015
Summary of Progress
Comment
Progress Report 3: 12/5/2015
Summary of Progress
Comment
Annual Review Date: 2/3/2016
Goal Met
Yes No Comments:

Page 8 of 17
MARIN CO. SELPA
ANNUAL GOALS AND OBJECTIVES

Student Name Arreola-Muro, Alexis

Area of Need: Organization

Date of Birth 2/9/2004

IEP Date: 2/3/2015

Measurable Annual Goal# 3

Goal: By 2/3/16, Alexis will increase his ability to keep his papers organized by
placing specified items in their designated folder within his binder, 80% of the
given opportunities across three consecutive days.

Baseline: Alexis struggled to maintain an

organized binder. He requires frequent
check-ins and prompting to place his papers
Enables student to be involved/progress in general curriculum/state
in the correct folders. Alexis places papers
in their designated folder 50% of the time. standard
Addresses other educational needs resulting from the disability
Linguistically appropriate
Transition
Goal:
Education/Training
Employment
Person(s) Responsible Classroom and RSP teachers

Independent Living

Progress Report 1: 3/21/2015

Summary of Progress Alexis has made some progress toward keeping an organized binder. Teacher check-ins should
continue.
Comment
Progress Report 2: 6/11/2015
Summary of Progress
Comment
Progress Report 3: 12/5/2015
Summary of Progress
Comment
Annual Review Date: 2/3/2016
Goal Met
Yes No Comments:

Page 9 of 17
MARIN CO. SELPA
Offer of FAPE - SERVICES
Student Name Arreola-Muro, Alexis

Birthdate 2/9/2004

IEP Date: 2/3/2015

The Service Options that were considered by the IEP team (In selecting LRE, describe the consideration is given to any
potential harmful effect on the child or on the quality of services that he or she needs): General Education, Specialized
Academic Instruction

Supplementary Aids, Services & Other Supports for school personnel, or for student, or on behalf of the student
Aids, Services, Program
Accommodations/Modifications,
and/or
Supports
Break information down into
manageable chunks, repeat
information, check for
understanding, use a cue for refocusing. Reinforce sustained
attention and completion of
smaller goals.
Special Education Transportation

Start Date

Student

02/03/2015

Personnel

No

End Date

02/03/2016

Frequency

as needed,
during
academic
tasks

Duration

throughout
the school
day

Location

Dixie School
District

Yes

SPECIAL EDUCATION and RELATED SERVICES

Service: Specialized Academic Instruction
Provider: District of Service
Duration/Freq: 30 min x 3 Totaling: 90 min served Weekly

Start Date: 2/3/2015

End Date: 6/11/2015

Ind
Grp
Sec Transition
Location: Separate classroom in public integrated
facility

Comments:
Service: Specialized Academic Instruction
Provider: District of Service

Start Date: 8/23/2015

End Date: 2/3/2016

Ind
Grp
Sec Transition
Location: Separate classroom in public integrated
facility
Comments: This service will start in the fall when Alexis transitions to Miller Creek Middle School.
Duration/Freq: 45 min x 5 Totaling: 225 min served Weekly

EXTENDED SCHOOL YEAR (ESY)

Yes No
Rationale: Alexis does not show significant regression over the summer period and his level of recoupment is within the
expected range and does not require an extended school year.

Programs and services will be provided according to when student is in attendance and consistent with the district of service
calendar and scheduled services, excluding holidays, vacations, and non-instructional days unless otherwise specified.

Page 10 of 17
MARIN CO. SELPA
Offer of FAPE - EDUCATIONAL SETTING

Student Name Arreola-Muro, Alexis

Physical Education

Date of Birth 2/9/2004

General

District of Service Dixie Elementary

Specially Designed

IEP Date: 2/3/2015

Other

School of Attendance Vallecito Elementary

School Type Public day school

Federal Setting Regular classroom/Public day school

Federal Preschool Setting
All special education services provided at student's school of residence?
Yes No (rationale)

3 % of time student is outside the regular class & extracurricular & non academic activities
97 % of time student is in the regular class & extracurricular & non academic activities

Student will not participate in the regular class & extracurricular & non academic activities
because Alexis requires individualized academic instruction to address academic goals
Other Agency Services
California Children's Services(CCS)
Probation
Dept. of Social Services(DSS)
Other

Regional Center
Department of Rehabilitation
County Mental Health (CMH)

Promotion Criteria:

District

Parents will be informed of progress

Quarterly

How?

Progress Summary Report

Progress on Goals
Trimester

Other

Semester

Other

Other

ACTIVITIES TO SUPPORT TRANSITION (e.g. preschool to kindergarten, special education and/or NPS to general education
class, 8th-9th grade, etc)
Alexis will have the opportunity to visit Miller Creek before starting in the fall.
GRADUATION PLAN (Grade 7 and Higher)
Projected graduation date and/or secondary completion date
10 To participate in high school curriculum leading to a diploma
20 To participate in high school curriculum leading to certificate of completion or other than diploma

Page 11 of 17
MARIN CO. SELPA
Statewide Assessments
Student Name: Alexis Arreola-Muro

Date of Birth: 2/9/2004

IEP Date: 2/3/2015

Indicate students participation in the California Assessment of Student Performance and Progress (CAASPP) below:
English Language Arts (Grades 3-8, & 11)
Out of testing range
SBAC without Designated Supports or Accommodations
SBAC with Designated Supports Embedded
SBAC with Designated Supports Non-embedded
SBAC with Accommodations Embedded
SBAC with Accommodations Non-embedded
SBAC with Accessibility Support (requires CDE Approval)
Alternate Assessment
Math (Grades 3-8, & 11)
Out of testing range
SBAC without Designated Supports or Accommodations
SBAC with Designated Supports Embedded
SBAC with Designated Supports Non-embedded
SBAC with Accommodations Embedded
SBAC with Accommodations Non-embedded
SBAC with Accessibility Support (requires CDE Approval)
Alternate Assessment
Science (Grades 5, 8 & 10)
Out of testing range
CST without Designated Supports or Accommodations
CST with Designated Supports
CST with Accommodations
CMA without Designated Supports or Accommodations
CMA with Designated Supports
CMA with Accommodations
CAPA Level

1.

2.

3.

4.

5.

If student is taking CMA, CAPA, or Alternate Assessment the IEP team has reviewed the criteria for taking alternate
assessments.
The student will not participate in the SBAC because
Participation in an Alternate Assessment is appropriate
Physical Fitness Test (Grades 5, 7 & 9)
Out of testing range
Without Accommodations
With Accommodations
With Modifications (Check with PFT Office prior to use)
CAHSEE (Grades 10-12, or ages 15+ and grade code is Ungraded)
Outside of testing range

Page 12 of 17
Without Accommodations
With Accommodations
CAHSEE with Modifications (waiver required)
Exemption/ Medical Exemption
To participate in Alternate Assessment
Other State-Wide/ District-Wide Assessment(s) Alternate Assessment(s)
Desired Results Developmental Profile (DRDP) (Preschoolers Ages 3, 4 and 5 years)
Not Applicable

Sensory support

Functional positioning

Alternative response mode

Assistive equipment or device

Visual support

Alternative mode for written language

Augmentative or alternative communication system

CELDT (English Learners Only)

Listening without Accommodations
Listening with Accommodations
Speaking without Accommodations
Speaking with Accommodations
Reading without Accommodations
Reading with Accommodations
Writing without Accommodations
Writing with Accommodations
Alternate Assessment to CELDT
If yes, areas of alternate assessment:
Listening
Speaking
Name of alternate assessment(s)
Person responsible to administer alternate assessment(s)
Standards based Tests in Spanish STS
Math without Accommodations
Math with Accommodations
Reading, Language, Spelling without Accommodations
Reading, Language, Spelling with Accommodations

Reading

Writing

Page 13 of 17
MARIN CO. SELPA
SPECIAL FACTORS

Student Name Arreola-Muro, Alexis

Date of Birth 2/9/2004

IEP Date: 2/3/2015

Does the student require assistive technology devices and/or services?

No Yes
Rationale
Alexis does not need technology that exceeds what general education peers have available in the classroom.
Does the student require low incidence services, equipment and/or materials to meet educational goals?
(if yes,specify)
Not required for this student.

No

Considerations if the student is blind or visually impaired: Not required for this student.
Considerations if the student is deaf or hard of hearing: Not required for this student.
If the student is an English Learner, complete the following section:
Does the student need primary language support?
No
What will be the language of instruction for the student?

Yes

if yes, who will provide?

Who will provide ELD services to student?

General Education

What type of ELD services will be provided?

English Language Mainstream

Structured English Immersion
Alternative Program (primary language instruction)

Special Education

Comments:
Does student's behavior impede learning of self or others?

No

Yes

If yes, specify positive behavior interventions, strategies, and supports

Behavior Goal is part of this IEP

Behavior Intervention Plan (BIP) attached

Yes

Page 14 of 17
MARIN CO. SELPA
IEP TEAM MEETING NOTES
Student Name Arreola-Muro, Alexis

Date of Birth 2/9/2004

Date 02/03/2015

Notes IEP Meeting participants:

Jorge and Esther, Parents
Tracy Smith, Principal
Terry Colyer, Teacher
Kristina Chino, RSP
Kelsey Olson, Student Teacher
Colleen Arnold, Dominican Observer
Meeting Purpose: Annual
Parent Rights: Parents rights were offered
Parent comments/concerns: Esther is concerned about the transition to 6th grade and the amount of support that Alexis will
receive at Miller Creek.
Asked Mrs. Colyer if she sees Alexis as more focused. Mom has recently upped his medication because he has grown and she
sees improvement with homework. Alexis has been stressed about homework.
Mom sees that positive feedback is helpful for Alexis and he is more motivated to stay focused and get his work done quicker.
Mom says that Alexis knows he needs to do the work and can't get out of it.
Mom is concerned about the amount of homework that will be assigned next year. We talked about the accommodations we
recommend for Alexis that will be following him to middle school.

Eligibility: 280 Other Health Impairment (OHI)

Present levels of performance: He is performing at grade level in math and below grade level in reading comprehension and
writing. Alexis is sweet and polite in the classroom. Alexis can improve on his participation during class discussions and seeking
help when needed. He has difficulty completing classwork and homework on time. Alexis needs help organizing his school
materials.
Mrs. Colyer doesn't see Alexis participate in whole class discussions. Front loading is very helpful. He has more trouble with
inference.
Annual Goals: Alexis has met his current goal in writing. He made progress towards his reading comprehension goal, but it was
not met. New goals were presented in the areas of reading comprehension, writing, and organization.
Accommodations/Modifications: Break information down into manageable chunks, repeat information, check for understanding,
use a cue for re-focusing. Reinforce sustained attention and completion of smaller goals.
Statewide Testing: No accommodations outside of universal tools needed. He will be able to take the assessment in a quiet
location and have as much time as he needs.
Placement: general education classroom with specialized academic support.
Services: RSP 30 min. three times a week. At Miller Creek: 45 min. daily.
ESY: Not required for this student.
Follow-up activities: Mrs. Chino and Ms. Olson will check in with Alexis' science teacher. He could use additional prompting to turn
in homework because he usually has it completed.
Parent agreement/disagreement: Parent agrees.
Prior Written Notice: Based on observation of the student, parent input, and evaluation of the IEP and the students needs, the
district believes the districts proposal provides the Least Restrictive Environment and a Free and Appropriate Public Education.
Parents have protection under procedural safeguards and a copy of the Procedural Safeguards was provided to the parent on
2/3/15. Parents may also contact their local Special Education Local Plan Area (SELPA) for further sources of information.

Page 15 of 17
MARIN CO. SELPA
SIGNATURE AND PARENT CONSENT
Student Name Arreola-Muro, Alexis

Date of Birth 2/9/2004

IEP Date 2/3/2015

IEP Meeting Participants

Parent/Guardian/Surrogate

Date

Parent/Guardian

Date

Student/Adult Student

Date

General Education Teacher

Date

LEA Representative/Admin.Designee

Date

Special Education Specialist

Date

Additional Participant/Title

Date

Additional Participant/Title

Date

Additional Participant/Title

Date

Additional Participant/Title

Date

Additional Participant/Title

Date

Additional Participant/Title

Date

Additional Participant/Title

Date

Additional Participant/Title

Date

CONSENT
I agree to all parts of the IEP.
I agree with the IEP, with the exception of
I decline the offer of initiation of special education services.
I understand that my child is not eligible for special education.
I understand that my child is no longer eligible for special education.
As a means of improving services and results for your child did the school facilitate parent involvement?
Yes
No
No Response
Signature below is to authorize and approve the IEP.
Signature

Date
Parent

Guardian

Surrogate

Adult Student

Signature

Date
Parent

Guardian

Surrogate

Adult Student

If my child is or may become eligible for public benefits (Medi-Cal): I authorize the LEA/district to release student information for
the limited purpose of billing Medi-Cal/Medicaid and to access Medi-Cal: health insurance benefits for applicable services.
Signature
Parent

Guardian

Surrogate

Adult Student

Parent/Adult Student has received a copy of the Procedural Safeguards

Parent/Adult Student has received a copy of assessment report (if applicable)
Parent/Adult Student has received a copy of the Individualized Education Plan (IEP)
Parent/Adult Student has received written notification of protections available to parents when LEA requests to access
Medi-cal benefits
Student enrolled in private school by their parents. Refer to Individual Service Plan, if appropriate.