"Revocation of Consent for Particular Special Education and Related Service(S) and/or Placement(S)" - Kansas

Revocation of Consent for Particular Special Education and Related Service(S) and/or Placement(S) is a legal document that was released by the Kansas Department of Education - a government authority operating within Kansas.

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  • Released on August 11, 2010;
  • The latest edition currently provided by the Kansas Department of Education;
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REVOCATION OF CONSENT
FOR PARTICULAR SPECIAL EDUCATION AND RELATED SERVICE(S) AND/OR PLACEMENT(S)
STUDENT NAME:
SCHOOL DISTRICT:
Effective
, I,
, having authority under
(Date)
(Name)
the laws of the state of Kansas to make educational decisions:
on behalf of the above named student
on my own behalf (adult student),
hereby revoke consent for the following special education and related service(s) and or placement(s) for the
above named student:
If the IEP team certifies in writing that the above named student does not need the special education and
related service(s) and/or placement(s) specified above in order to receive a free appropriate public education
(FAPE), I understand that, after providing me with prior written notice of the termination of services:
(a) this revocation of consent will result in the school district discontinuing only the above specified
service(s) and/or placement(s) and that all other provisions in the IEP will be continued;
(b) this revocation of consent does not negate an action that occurs after consent is given and before
consent is revoked; and
(c) the school district will not be considered to be in violation of the requirement to make a FAPE in the
least restrictive environment available to the student because of the discontinuation of the service(s)
and/or placement(s) specified above.
If the IEP team determines that the student needs the special education and related service(s) and/or
placement(s) specified above to receive a FAPE, I understand that:
(a) the service(s) and/or placement(s) specified above will continue;
(b) I retain all of the procedural safeguards specified in federal and state special education laws and
regulations; and
(c) I may request mediation or initiate a due process hearing to challenge the IEP team’s decision that the
special education service(s) and/or placement(s) specified above are needed in order for the student to
receive a FAPE.
(Signature)
(Date)
As the school representative on this student’s IEP team, I,
,
(Name)
certify, on behalf of the IEP team, that this student’s IEP team considered the revocation of consent described
above and that the team determined that the student
does
does not need the special education and
related service(s) and/or placement(s) specified above in order to receive a free appropriate public education
(FAPE).
(Signature)
(Date)
KSDE Sample Forms,
August 11, 2010
Revocation of Particular Services
REVOCATION OF CONSENT
FOR PARTICULAR SPECIAL EDUCATION AND RELATED SERVICE(S) AND/OR PLACEMENT(S)
STUDENT NAME:
SCHOOL DISTRICT:
Effective
, I,
, having authority under
(Date)
(Name)
the laws of the state of Kansas to make educational decisions:
on behalf of the above named student
on my own behalf (adult student),
hereby revoke consent for the following special education and related service(s) and or placement(s) for the
above named student:
If the IEP team certifies in writing that the above named student does not need the special education and
related service(s) and/or placement(s) specified above in order to receive a free appropriate public education
(FAPE), I understand that, after providing me with prior written notice of the termination of services:
(a) this revocation of consent will result in the school district discontinuing only the above specified
service(s) and/or placement(s) and that all other provisions in the IEP will be continued;
(b) this revocation of consent does not negate an action that occurs after consent is given and before
consent is revoked; and
(c) the school district will not be considered to be in violation of the requirement to make a FAPE in the
least restrictive environment available to the student because of the discontinuation of the service(s)
and/or placement(s) specified above.
If the IEP team determines that the student needs the special education and related service(s) and/or
placement(s) specified above to receive a FAPE, I understand that:
(a) the service(s) and/or placement(s) specified above will continue;
(b) I retain all of the procedural safeguards specified in federal and state special education laws and
regulations; and
(c) I may request mediation or initiate a due process hearing to challenge the IEP team’s decision that the
special education service(s) and/or placement(s) specified above are needed in order for the student to
receive a FAPE.
(Signature)
(Date)
As the school representative on this student’s IEP team, I,
,
(Name)
certify, on behalf of the IEP team, that this student’s IEP team considered the revocation of consent described
above and that the team determined that the student
does
does not need the special education and
related service(s) and/or placement(s) specified above in order to receive a free appropriate public education
(FAPE).
(Signature)
(Date)
KSDE Sample Forms,
August 11, 2010
Revocation of Particular Services