Parents Engaged for Learning Equality

PARENTS ENGAGED FOR LEARNING EQUALITY (PELE) SPECIAL EDUCATION ADVOCACY CLINIC Application for Services

Please complete this form and return to the PELE Clinic. Providing this information does not mean that the clinic is representing you or that we agree to represent you. Actual representation will occur only if a separate agreement of representation is signed by you and the Clinic. Information provided with this application will be kept confidential. If more space is needed to fully answer the questions, please use additional paper. Date ______

Child’s Name ______Last First Middle Initial “Nickname”

Individual completing application:______*Be sure to include your contact information if it is different from family contact information.

Family Contact Information

Street Address______City, State Zip Code

Mother’s Name______Father’s Name______

Step-parent or Guardian’s Name (if living with child)______

Home Phone______Work Phone______Cellular Phone______

Email Address______Preferred Method of Communication______

Child Client Information

Date of birth______Age (years and months)______Sex ______

Child’s Current School______Grade in School______

How long has the child been at current school?______

Description of the child’s present educational program______Please list all schools the child has attended beginning with the child’s first educational experience. Include grade and year in attendance at each school.______

Which person at the child’s present school is most familiar with the child’s progress or lack of progress?______

Please list the names of all public and private agencies and/or individuals (including psychologists, psychiatrists, educational diagnosticians, counselors, tutors, etc.) with whom the child has had any contact. Include the name, approximate date of service, and the telephone number for each, starting with the most recent. a) ______b) ______c) ______d) ______e) ______

If applicable, please provide the contact information for any current or previous advocate or attorney who represented the child for special education needs:______

Child Eligibility Information

Nature of Child’s Disability______

Diagnosis of Disability______

First date of diagnosis______Date of last diagnosis______

Current Prescribed Medications______

Has child been evaluated for special education? If so, when and by whom?______Does child have an IEP? ______Date of last IEP ______

Description of current special education accommodations and/or modifications:______

Nature of the Problem

Description of child’s current problem______

What, in your opinion, needs to be done in order for child to receive an appropriate education?______

Desired outcome and goals for the child, and the ways in which you hope the clinic can help: ______

Do you have a complete copy of child’s current file from the public schools?______

Do you have a complete copy of child’s current file from other individuals/agencies?______

How did you hear about the PELE Clinic? ______

Thank you for contacting the PELE Clinic. Someone from the Clinic will contact you within two weeks of our receipt of this completed application.

PELE Clinic William & Mary Law School P.O. Box 8795 Williamsburg, Virginia 23187-8795 757-221-5735 [email protected]