Request for Special Education MediationAvailable in Word for Download or Printing |
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): |
|
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. |
|
Name of Person Completing this Form:
|
|
|
Signature:
|
Date: |
|
Relationship to Student: _____________________________________________________ |
|
Date of Receipt of Form: ______________________