Sonoma County SELPA

Parentally Placed Private School Student: Annual/Triennial Notification of Offer of FAPE

☐ Annual ☐Triennial

Student:Click here to enter text.Date: Click here to enter text.

Date of birth:Click here to enter text.

District of Residence: Click here to enter text.

Private School: Click here to enter text.

Dear Parent/Guardian,

All children with disabilities eligible for special education and related services who reside in the Sonoma County SELPA are entitled to a Free Appropriate Public Education (FAPE) if they are enrolled in a public school. Should you choose to enroll your child in your local public school, your child’s District of Residence (DOR) Click here to enter text. , is prepared to provide your child FAPE and an Individualized Education Program (IEP) in accordance to his/her special education and related services needs.

Please complete this form indicating your agreement with one of the following:

I understand that my child’s District of ResidenceClick here to enter text.continues to offer my child FAPE (including appropriate special education and related services) if he/she is enrolled in public school. I continue to voluntarily place my child in a private school and:

☐ I am NOT interested in enrolling my child in public school

OR

☐ I am interested in enrolling my child in public school.

I would like to schedule an IEP/triennial team meeting for my child. Please call me at Click here to enter text.in order to schedule this activity.

Return completed form within five (5) calendar days to:

Attention: Click here to enter text.School District: Click here to enter text.

Phone #: Click here to enter text.Fax #: Click here to enter text.

Address: Click here to enter text.

Parent/Guardian Printed Name: Click here to enter text.

______Date: Click here to enter text.

Parent/Guardian Signature

Enclosures: Special Education Services to Private School Student

SELPA Form #59 Copy 1: District of Residence Copy 2: District of Location Copy 3: Parent