Name: / Campus:
D.O.B.: / Grade:
Contact Person: / Phone:
All students inthe Mercedes Special Education Cooperative aged 14 and above with an individual education plan (IEP)that includes coordinated, measurable, annual IEP goals are eligible for transition servicesthat will reasonably enable the student to meet the postsecondary goals outlined in the student’s IEP.
The Mercedes Special Education Cooperative needs parent/adult student consent in order to release personally identifiable information to outside agencies which may be able to provide post secondary higher education connections that facilitate successful post secondary outcomes.
Information to be released may include name, social security number, birth date, grade, and/ or disabilities.
□I authorize the Mercedes Special Education Cooperative to release personally identifiable information and invite the following entities to the ARD/IEP meeting regarding the above named student:
□Division of Assistive and Rehabilitative Services
□Texas Tropical/ Mental Health and Mental Retardation
□Texas Workforce Commission
□Texas Rehabilitative Commission
□RegionOneEducationCenter
□Other: ______
□Other: ______
□I have been fully informed and understand the request for my consent as described above regarding the release of information.
□I understand that my consent is voluntary and may be revoked at any time. If I revoke consent, I understand that the revocation is not retroactive (i.e., it does not negate an action that has occurred after the consent was given and before the consent was revoked).
______
Signature of Parent, Guardian, Surrogate Parent or Adult Student Date
Signature of Interpreter/Campus Case Manager
□I DO NOT authorize the Mercedes Special Education Cooperative to release personally identifiable information and invite the entities named above to the ARD/IEP meeting regarding the student named above.
______
Signature of Parent, Guardian, Surrogate Parent or Adult Student Date
Signature of Interpreter/Campus Case Manager