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PROCEDURAL SAFEGUARDS NOTICE

APPENDIX B

Part A

MEDIATION REQUEST FORM

Mediation requested by:

Parent

School District (LEA)

Date:

Student’s Name:

Date of Birth:

Male

Female

Student’s Exceptionality:

Student’s School Building/Placement:

School District (LEA):

Superintendent:

School District Contact Person:

Title:

Phone No.:

Ext.:

Cell No.:

Fax No.:

Email:

Address:

Mother:

(First name)

(Last name)

Father:

(First name)

(Last name)

Parent Address:

Mother (work phone):

Father (work phone):

Mother (cell phone):

Father (cell phone):

Mother (email):

Father (email):

Parent Name (if not living with student):

Parent Address (if not living with student):

INFORMATION ABOUT THIS MEDIATION:

Please provide a brief description of the dispute below in order to facilitate the scheduling of the mediation.

Parent Issues:

School District (LEA) Issues:

Has a Due Process Hearing also been requested for this student?

NO

YES

28July 2008 Revisions

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