Request for Due Process Proceedings

Federal law requires that a parent or attorney representing a child provide notice to the school district if the parents have a disagreement regarding the referral, evaluation, or placement or their child or regarding the provision of special education services. (This notice will remain confidential.) This form has been developed to assist you in describing your disagreement and accessing the due process procedures to which you are entitled. Please print out this form, complete the entire form and submit it to your school district. Failure to do so may result in it being returned for additional information. According to Federal law, failure to provide information may result in a reduction in the award of any attorneys’ fees.

Student’s Name: ____________________________ Date of Birth:_________________

Parent or Legal Guardian: _________________________________________________

Legal Residence: Street ________________________________________________

City or Town ________________________ Zip Code ____________

Telephone: (        ) ______________________

Current School:     ______________________________________________

School Address: Street __________________________________________

City or Town __________________________________________________

Zip Code _____________

School district of attendance, if different from district of residence:

___________________________________

Fully describe the nature of the problem including all specific facts relating to the disagreement (Attach additional pages or documents as necessary):

State your proposed solution to the problem or the reason why you are unable to suggest a solution at this time. (Attach additional pages or documents as necessary):

Upon receipt of this form, you will be contacted to establish a mutually agreeable time to participate in mediation with an outside mediator and representative(s) of the district to attempt to resolve this disagreement. If mediation is unsuccessful, an impartial hearing will be conducted unless you inform the district in writing that you do not wish to proceed with a hearing. Participation in mediation will not delay or preclude your right to a due process hearing.

If you do not wish to attempt to resolve this problem through mediation prior to a hearing, please check the box below:

[   ] I do not wish to participate in mediation and request that the district schedule an impartial hearing at this time. (Please note: You may be requested to participate in a meeting to discuss the benefits of mediation.)

 

Name of Person Completing this Form: ______________________________________

Signature: _____________________________________ Date: __________________

Relationship to Student: [ ] Parent [ ] Legal Guardian   [ ] Surrogate Parent   [ ] Attorney

Date of Receipt of Form: _____________________________

Return this form to: ________________________________________________________

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