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Special Education Advocacy Intake Form
First Name
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Last Name
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Relationship to Student
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How are you related to this student?
Parent/Caregiver
Legal Guardian/State Employee
Educational Professional
Email
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Phone Number
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Street address
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City
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State/Region
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Zipcode
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Preferred language
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Please Select
Afrikaans
Albanian
Albanian - Albania
Arabic
Arabic - Algeria
Arabic - Bahrain
Arabic - Egypt
Arabic - Iraq
Arabic - Jordan
Arabic - Kuwait
Arabic - Lebanon
Arabic - Libya
Arabic - Morocco
Arabic - Oman
Arabic - Qatar
Arabic - Saudi Arabia
Arabic - Sudan
Arabic - Syria
Arabic - Tunisia
Arabic - United Arab Emirates
Arabic - Yemen
Armenian
Basque
Belarusian
Belarusian - Belarus
Bulgarian
Bulgarian - Bulgaria
Catalan
Catalan - Catalan
Chinese
Chinese - China
Chinese - Hong Kong SAR
Chinese - Macau SAR
Chinese - Singapore
Chinese - Taiwan
Chinese (Simplified)
Chinese (Traditional)
Croatian
Croatian - Croatia
Czech
Czech - Czech Republic
Danish
Danish - Denmark
Dutch
Dutch - Belgium
Dutch - The Netherlands
English
English - Australia
English - Canada
English - Hong Kong
English - India
English - Ireland
English - Malaysia
English - Malta
English - New Zealand
English - Philippines
English - Singapore
English - South Africa
English - United Kingdom
English - United States
English - Zimbabwe
Estonian
Estonian - Estonia
Faroese
Farsi
Finnish
Finnish - Finland
French
French - Belgium
French - Canada
French - France
French - Luxembourg
French - Monaco
French - Switzerland
Galician
Georgian
German
German - Austria
German - Germany
German - Greece
German - Liechtenstein
German - Luxembourg
German - Switzerland
Greek
Greek - Cyprus
Greek - Greece
Gujarati
Hebrew
Hebrew - Israel
Hindi
Hindi - India
Hungarian
Hungarian - Hungary
Icelandic
Icelandic - Iceland
Indonesian
Indonesian - Indonesia
Irish
Irish - Ireland
Italian
Italian - Italy
Italian - Switzerland
Japanese
Japanese - Japan
Kannada
Kazakh
Konkani
Korean
Korean - South Korea
Kyrgyz
Latvian
Latvian - Latvia
Lithuanian
Lithuanian - Lithuania
Macedonian
Macedonian - Macedonia
Malay
Malay - Brunei
Malay - Malaysia
Maltese
Maltese - Malta
Marathi
Mongolian
Burmese
Burmese - Myanmar (Burma)
Norwegian
Norwegian Bokmal
Norwegian - Norway
Polish
Polish - Poland
Portuguese
Portuguese - Brazil
Portuguese - Portugal
Punjabi
Romanian
Romanian - Romania
Russian
Russian - Russia
Sanskrit
Serbian
Serbian - Bosnia and Herzegovina
Serbian - Montenegro
Serbian - Serbia
Serbian - Serbia and Montenegro (Former)
Slovak
Slovak - Slovakia
Slovenian
Slovenian - Slovenia
Spanish
Spanish - Argentina
Spanish - Bolivia
Spanish - Chile
Spanish - Colombia
Spanish - Costa Rica
Spanish - Cuba
Spanish - Dominican Republic
Spanish - Ecuador
Spanish - El Salvador
Spanish - Guatemala
Spanish - Honduras
Spanish - Mexico
Spanish - Nicaragua
Spanish - Panama
Spanish - Paraguay
Spanish - Peru
Spanish - Puerto Rico
Spanish - Spain
Spanish - United States
Spanish - Uruguay
Spanish - Venezuela
Swahili
Swedish
Swedish - Finland
Swedish - Sweden
Syriac
Tamil
Tatar
Telugu
Thai
Thai - Thailand
Turkish
Turkish - Turkey
Ukrainian
Ukrainian - Ukraine
Urdu
Vietnamese
Vietnamese - Vietnam
Bengali
Tagalog
Malayalam
Assamese
Cebuano - Philippines
Hausa
Kiswahili
Kinyarwanda
Nyanja
Malagasy
Yoruba
Haitian Creole
Student Information
Student's First Name
*
Student's Last Name
*
Birthdate
Month
/
Day
/
Year
Gender
*
M-Male F-Female N-Non-binary
Current Grade Level Placement
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Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Residential Treatment Facility
Group Home
Student Plan Status
*
Check ALL that apply
Evaluation Phase
IEP/BIP
504
Former IEP/BIP
Former 504
ELL
RTI/MTSS
N/A
Disability Category
*
Select your child's disability category.
N/A
Autism Spectrum Disorder
Other Health Impairment
Specific Learning Disability
Emotional Disability
Speech-Language Impairment
Hearing Impairment
Visual Impairment
Deafness
Blindness
Deafness-Blindness
Traumatic Brain Injury
Intellectual Disability
Orthopedic/Physical Disability
Multiple Disabilities
FERPA gives parents certain rights with respect to their children's education records. These rights transfer to the student when he or she reaches the age of 18 or attends a school beyond the high school level. Students to whom the rights have transferred are "eligible students."
Parents or eligible students have the right to inspect and review the student's education records maintained by the school. Schools are not required to provide copies of records unless, for reasons such as great distance, it is impossible for parents or eligible students to review the records. Schools may charge a fee for copies.
Parents or eligible students have the right to request that a school correct records which they believe to be inaccurate or misleading. If the school decides not to amend the record, the parent or eligible student then has the right to a formal hearing. After the hearing, if the school still decides not to amend the record, the parent or eligible student has the right to place a statement with the record setting forth his or her view about the contested information.
Generally, schools must have written permission from the parent or eligible student in order to release any information from a student's education record. However, FERPA allows schools to disclose those records, without consent, to the following parties or under the following conditions (34 CFR § 99.31):
-School officials with legitimate educational interest;
-Other schools to which a student is transferring;
-Specified officials for audit or evaluation purposes;
-Appropriate parties in connection with financial aid to a student;
-Organizations conducting certain studies for or on behalf of the school;
-Accrediting organizations;
-To comply with a judicial order or lawfully issued subpoena;
-Appropriate officials in cases of health and safety emergencies; and
-State and local authorities, within a juvenile justice system, pursuant to specific State law.
FERPA Authorization - Check this box if you consent to granting permission to the staff at Realized Curriculum Solutions to access your child's educational records?
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Explanation
Briefly describe your child's needs.
Student Records
*
Upload your child's educational records
Reference
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