IEP Agency Consent Attendance

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					Clinton City Schools Exceptional Children Program
606 College Street Clinton NC 28328 910-592-3132  Fax 910-592-2011
Robert P. Taylor, EC Director                                                 Joy Culbreth, Administrative Assistant




                          IEP Agency Attendance Consent Form (Student)

To: ____________________________________
                   (Student Name)

__________________________ School has scheduled an IEP meeting for you on _______________ and is
requesting your consent for the agency and its representative(s) listed below to attend this meeting. This
agency(s) may be responsible for providing services identified in the IEP and may possibly provide input on the
implementation of the IEP. North Carolina law requires that if you as a student that have reached the age of
majority, we have your consent before an agency has permission to attend and provide input during an IEP
meeting. If you do not consent to the agency(s) attendance please indicate below by signing in the appropriate
space. If you have additional questions, contact the teacher listed below for additional information.

Teacher Name:________________________ Phone Number________________________________


Agency Name(s)___________________________ Representative(s)__________________________

_________________________________________________________________________________

Agency Name:____________________________ Representative(s)__________________________

_________________________________________________________________________________


I give my consent for the above listed agency(s) and their representative(s) to attend the IEP meeting on the date
listed above.

________________________________________
                Student Signature




I DO NOT give my consent for the above listed agency(s) and their representative(s) to attend the IEP meeting
on the date listed above.

________________________________________
                Student Signature




                                          Connecting Dreams to the Future
Clinton City Schools Exceptional Children Program
606 College Street Clinton NC 28328 910-592-3132  Fax 910-592-2011
Robert P. Taylor, EC Director                                               Joy Culbreth, Administrative Assistant




                                          Connecting Dreams to the Future

				
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