Special Education Local Plan Areas (SELPAs) Representing: San Juan, Sacramento City, Elk Grove, Folsom Cordova and Sacramento County
NOTIFICATION OF SURROGATE PARENT AUTHORIZATION
In accordance with AB 1528 (Chapter 182, Statutes of 1990), and General Regulation Sections 300.514 of the Code of Federal Regulations, the Sacramento County SELPA shall ensure that the rights of the child are protected.
In compliance, <Name of Surrogate Parent here> , has been appointed and has agreed to act as a surrogate parent for: <Name of Child here> .
The appointed surrogate must represent the child in all matters relating to identification, assessment, instructional planning and development, educational placement, review and revision of the individualized education program, and provision of a free and appropriate education for the child.
< surrogate parent’s name here>
< surrogate parent’s full address here>
<date here>
Surrogate Parent
Surrogate Parent’s Address
Date
<surrogate parent’s telephone number here>
<surrogate parent’s alternate phone here>
Telephone Number
Alternate Contact Phone
<SELPA/District Designee Name here>
<Applicable SELPA Name here> <date here>
SELPA/District Designee
SELPA Name
Chapter 4 – Procedural Safeguards, Charter SELPA
Page 101
As of 11/18/2016
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