Free JV-537.v16.101507.xyz.ofm - California

JV-537
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: FOR COURT USE ONLY

CHILD'S NAME:

EDUCATIONAL REPRESENTATIVE OR SURROGATE PARENT INFORMATION

CASE NUMBER:

To the educational representative or surrogate parent of the child: You may submit written information to the court or to the child's social worker or probation officer, and you may attend review hearings. This optional form may assist you in providing written information to the court. Please type or print clearly in ink and submit the form well in advance of the hearing but no later than seven days prior to the hearing. Please provide five additional copies to the clerk. 1. a. b. c. d. 2. a. b. c. d. e. Child's date of birth: Child's age: Child's school: Child's grade level: Name of educational representative or surrogate parent: Address: Telephone: I was appointed as educational representative or surrogate parent on (date): I was appointed as educational representative or surrogate parent by (name): (1) Local education agency in (school district): (2) Juvenile court in (county): (3) Other (specify): I am resigning from my appointment.

f.

3. Since my appointment as educational representative or surrogate parent, or since my last form JV-537 statement, I have performed the following actions on behalf of the child (specify):

4. 5.

I do not have any new or additional information since the last court hearing. I have new or additional information since the last court hearing (e.g., changed school, school discipline):

6.

Based on my observations of the child's physical, emotional, mental, and social development, I believe the child (0­3 years old) may be eligible for early intervention services. a. may have a disability (explain): b.

7.

The child has the following disabilities (specify):

8.

The child has the following educational needs (specify):

Page 1 of 2 Form Approved for Optional Use Judicial Council of California JV-537 [New January 1, 2008]

EDUCATIONAL REPRESENTATIVE OR SURROGATE PARENT INFORMATION

Cal. Rules of Court, rule 5.650 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com

JV-537
CHILD'S NAME:
CASE NUMBER:

9.

The child requires the following services to meet his or her educational needs (specify):

10.

The child is receiving the following education-related services or accommodations (explain):

a. These services or accommodations

are

are not appropriate (explain):

b. Date of most recent individualized education plan (IEP) or section 504 plan:

11.

On (date): I made a request for assessments from the a. regional center (name): b. local education agency (name): c. other (name):

12. a. Type of assessments requested (check all that apply): Individualized education plan (1) Section 504 plan (2) (3) Individual family plan AB 3632 county mental health assessments (4) Psycho-educational assessment (5) Other (specify): (6) b. Reason requested (specify):

13.

If you need more space to respond to any section above, please check this box and attach additional pages. Number of pages attached:

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF EDUCATIONAL REPRESENTATIVE OR SURROGATE PARENT )

JV-537 [New January 1, 2008]

EDUCATIONAL REPRESENTATIVE OR SURROGATE PARENT INFORMATION

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