Agency Communication and Referral Consent Form for the Sheppard Pratt School - Glyndon Campus

This consent form authorizes the Sheppard Pratt School to communicate with the agencies that may provide services or support to eligible individuals if they meet the specific criteria of the agency. This consent may include inviting a representative from an agency listed below to the student's IEP meeting. Your consent is voluntary and may be revoked at any time.

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Email *
Student's Full Name *
Department of Rehabilitation Services (DORS): "I authorize The Sheppard Pratt School to communicate with and refer my child to DORS." *
Required
Developmental Disabilities Administration (DDA): "I authorize The Sheppard Pratt School to communicate with the DDA about my child."
*
Required
Maryland Department of Labor (MDL): "I authorize The Sheppard Pratt School to communicate with the MDL about my child."
*
Required
Behavioral Health Administration (BHA): "I authorize The Sheppard Pratt School to communicate with the BHA about my child."
*
Required
"My child is currently connected with the following agencies and the representatives with whom we are working."
Name(s) of agency representatives with whom you are working.
Please initial in the space below that you have been informed that rights under IDEA (Individuals with Disabilities Education Act) do not transfer to students with disabilities on reaching age of majority, except under limited circumstances, as described in Education Article §8-412.1, Annotated Code of Maryland.
*
"My electronic signature below indicates that the selected items accurately reflect my elected connections to the agencies listed above."
Parent/Guardian's Electronic Signature *
Date signed *
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