KYRENE SCHOOL DISTRICT, 8700 S. Kyrene Road, Tempe, AZ 85284
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Student Name_______________________________ DOB________________ Home School______________ Meeting Date_____________ Annual Review Date_______________3-Year Re-Evaluation Date____________ Parent/Guardian Name_____________________________________________________________________ Phone: work/____________________________________home/____________________________________ Address_________________________________________________________________________________ |
____I have met with a district representative who has explained the free and appropriate public education provided by the district to students with disabilities. However, I am electing to enroll my child in a private/home school, ____________________________ School. Listed below are the services to be provided to my child: |
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____I have met with the IEP team that has developed an IEP describing a free and appropriate public education for my child. However, I am electing to enroll my child in a private/home school, ____________________________ School. Listed below are the services to be provided to my child: |
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Type of Service
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Frequency ____________________ ____________________ ____________________ |
Location of Service ________________________ ________________________ ________________________ |
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Signatures |
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Distribution: 1) District Office 2) Special Education Teacher 3) Parent 4) Related Services Provider(s)
8/2001