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AUTHORIZATION TO ADVOCATE

and

DESIGNATION OF STUDENT/PARENT EDUCATIONAL REPRESENTATIVE

 

 

     I/we ____________________________________________________________, hereby authorize Roger N. Meyer, D.B.A "of a different mind," to be my (our) advocate and parent educational representative in matters relating to my (my/our child's) special education at the school district identified below.  Mr. Meyer is authorized to conduct conversations and exchange correspondence with all persons relating to my (my/our child's) special educational issues.  Such persons may include, but are not limited to the school district or educational service district (ESD) special educational representative, my (my/our child's) general curriculum teacher(s), school district and ESD employed and contract service providers, and officials of the Oregon Department of Education.

 

     Mr. Meyer is authorized to view my (my/our child's) complete educational records, including but limited to enrollment, attendance, tests and measures results and protocols, evaluation summaries and grade reports, complete special education file, discipline or other files with his/her identifiers, and all privately held "sole possession" teacher and administrator notes and correspondence wherein my child is identified by name and are known to have been shared by the possessor with others, and any materials defined as Educational Records in the Federal Educational Records Privacy Act (FERPA).  In my (our) absence and on my (our) behalf, he is further authorized to attend any meetings relating to special education evaluations, IEP's, manifestation determination team meetings, and transition team issues.

 

     This authorization is effective as of the date of my (our) signature, and can be revoked by me (us) at any time.  Absent revocation, this authorization will remain effective for the entire time, including summer vacations and holidays and post-graduation transition during which I am (my/our child is) enrolled in the school district as a special education student.

 

 

___________________________________                          _____________

                            Signature                                                            Date

 

___________________________________                          _____________

                            Signature                                                            Date

 

___________________________________                          _____________

                    ROGER N. MEYER                                                   Date

 

 

 

School District and ESD_________________________________________

 

 

 

A separate HIPAA/FERPA compliant release and authorization may be included with this notice.

 

OADM  SPED Advocacy and Student/Parent Educational Representative Authorization  09/04

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