Special Education

Request for Special Education Mediation

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This sample form has been developed by the New York State Education Department (NYSED) to assist parents in describing disagreements and accessing special education mediation to resolve disputes. State law requires that a request for mediation be in writing.  Although it is not required to use this form, it will assist all parties to better understand the issues in dispute and proposed resolution.

Directions:  Please print out this form. When completed submit the form to your school district. (Do not send this form to NYSED.)

Student’s Name: Date of Birth:
Parent or Legal Guardian:
Legal Residence Street:
City or Town:
 
Zip Code:
Daytime Telephone Number:
(        )
Email Address:

 

Current School:
School Address Street:
City or Town:
 
Zip Code:
School district of attendance, if different from district of residence:

Subject of the Complaint

Mediation is requested to assist in resolving the following issue(s):
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______________________________________________________________________ ______________________________________________________________________
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______________________________________________________________________
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Proposed Solution

State your proposed solution to the problem to the extent known and available at this time.  Attach additional pages or documents as necessary.
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_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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Name of Person Completing this Form:
Signature:
Date:
Relationship to Student:
_____________________________________________________

 

Date of Receipt of Form: ______________________

Last Updated: June 12, 2014