The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office for Special Education Services
Room 1621 - One Commerce Plaza
Albany, NY  12234
(518) 473-6108
(518) 473-5769 Fax

APPLICATION TO THE COMMISSIONER OF EDUCATION FOR APPROVAL FOR AN EVALUATION TO ATTEND A 4201 STATE-SUPPORTED SCHOOL - PHC-10 - Word Word Document (51 KB)

INSTRUCTIONS

  1. Please PRINT or TYPE the information on this application.

  2. The appropriate examination(s) as listed below, administered within the last 12 months, must be submitted with this form to determine the student's eligibility.

NOTE:  During the processing of this Application it is necessary that your child remain in his or her current placement to ensure the continuity of his/her educational program.

For further assistance in completing this application please contact the Office listed above.

1. Child's Name ____________________________ 2. Date of Birth        /       /     
  (Last)  (First) _____F _____M
3. Parents'/Guardians Names                   
4. Address                        ________                       
(Street)  (City)    (State) (Zip Code)
County of Location                     
5. Telephone Number  (      )                                   
6. Local School District of Residence ___________________________________
Address __________________________________________________________
(Street)  (City)    (State) (Zip Code)
Telephone Number  (       )  _____________________ Fax  (      )_____________________
7.Indicate the dominant language used in the home:
8.Indicate child's primary disability (check only one)
Deaf............................................................o
Functionally Deaf....................................... o

Blind ..........................................................o

Deaf/Blind ............................................... .o		 Legally Blind ...................................o

Physically Disabled..........................o

 Emotionally Disturbed......................o
9.If child has multiple disabilities (check all that apply)

Mentally Retarded .................................o

Autistic ..................................................o

Emotionally Disturbed ...........................o

Speech Impaired ...................................o

Deaf ......................................................o

Hard of Hearing ................................o

Visually Impaired ..............................o

Orthopedically Impaired ...................o
10.Indicate current educational placement of child.
School Name________________________________________ Phone  (      )    
Program Administrator                   
Address                 
(Street)  (City)                      (State)              (Zip Code)

 

PERSON COMPLETING THIS APPLICATION
NAME              
TITLE                             
PHONE                           
Date                                                    

                        

Signature of Parent or Guardian

   

SED Use Only

Dear Parent(s):

Your child has been recommended and approved for an evaluation at the 4201 State-supported school indicated below. This office has approved this evaluation to be conducted for your child at the State-supported school effective as of the date of this approval. It will be necessary for you to contact the State-supported school indicated below to make the necessary arrangements so that your child may be evaluated promptly.  The results of this evaluation will be forwarded to your school district Committee on Special Education/Committee on Preschool Special Education for their review. Should you have any questions, please contact this office at (518) 473-6108.

Sincerely,

                                            ______________

  Signature of State Representative                                        

__________________________

Date

 

cc:       CSE, CPSE, REGION, CBST
4201 School _____________________________________________________