ISS Informed Consent for Services

Informed Consent-English Language Learner (ELL)

Today's Date *

Student's Name *

First

Last

Student's Date of Birth *

School *

Grade *

Classroom/Homeroom Teacher *

Parent/Guardian *

First

Last

Parent/Guardian

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

As the parent/guardian of the student named above, I hereby give my consent to School District 46 (Sunshine Coast) for the following assessment/consultation (indirect or direct) *

Karen Broom-Teacher, English Language Learner (ELL)
Helen Baron-Teacher, English Language Learner (ELL)
Jessica Swanson , English Language Learner (ELL)

to consult and/or to assess my child and to provide assessment findings, recommendations, resources and training to school personnel (e.g. Principal, Teacher, EA, Inclusion Support Staff). I understand that my child's school and I will be provided with copies of any reports and that the results of all assessments and recommendations may be discussed with me. *

Clear Signature

Parent/Guardian Signature

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ISS Informed Consent for Services

Informed Consent-English Language Learner (ELL)

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