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