Bi- County Special Education Cooperative, Serving Whiteside and Carroll Counties
506 W. 4th St., Suite B; Sterling, Illinois 61081; Phone (815) 622-0858; Fax (815) 622-3182             www.bi-county.org

AUTISM CONSULTATION CONSENT

Name of Student:

Birth Date:

 School:

 Grade:

I hereby give consent for the Bi-County Autism Team to become involved in one or more of the following activities pertaining to the above mentioned student:

        1. Conduct classroom observations

        2. Interview school personnel

        3. Review school records

        4. Participate in parent-teacher meetings

Signature of Parent/Guardian:________________________             Date:_______

*Please return this form to your child’s teacher who will forward it to Bi-County.

________________________________________________________

Teachers:      Please fax then mail the original of this completed form to Linda Rodriguez at Bi-County.