Date:_____/___/_____

Your Name: ________________________

Your Full mailing address: ________________________

________________________

________________________

Name of the Principal: ________________________

School’s mailing address: ________________________

________________________

________________________

Dear ___________________________:

This is a written referral pursuant to NC 1503-2.2 Policies Governing Services for Children with Disabilities, to request that my child, __________________, be evaluated for exceptional children’s services. His/her date of birth is __________________. I am concerned about his/her educational progress because: ______________________________________________________________________

Please contact me to schedule a time to meet with you to discuss the process as soon as possible. Please accept this request as written consent to evaluate my child to determine eligibility for special education services.

I look forward to hearing from you soon. My daytime telephone number is _________________________________________________. Thank you for your time.

Sincerely,

___________________________

(parent)