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Revocation of Resource Services
Parent/Guardian Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Student Name
(Required)
First
Last
Student Grade
(Required)
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th - Freshman
10th - Sophomore
11th - Junior
12th - Senior
Parent Acknowledgement
Consent: I am parent/guardian
(Required)
I am the parent or legal guardian of the above referenced student, who is currently enrolled at Trinity Christian Academy, and eligible to receive resource service support.
(Required)
Consent: revoke resource services
(Required)
I revoke my consent to the provision of support from our Resource Department for my student. I understand that by revoking my consent to the provision of resource services, certain rights and services will no longer be provided to my student.
(Required)
Consent: change mind
(Required)
I understand that, if at any time, I change my mind and request my student to return to special education, Trinity Christian Academy Resource Department, with the approval of Administration, will conduct appropriate assessment and convene an AIP meeting to determine eligibility and if services are deemed necessary or accommodations can be made, an appropriate plan will be made for placement back into the program.
(Required)
Consent: probation
(Required)
I understand that my student may be placed on a one quarter or one semester probationary period once services are revoked. Administration reserves the right to call a parent AIP meeting and/or Parent Teacher conference, if the student is not making academic progress and requires reinstatement of resource services.
(Required)
Signature
(Required)
