480-587-3220

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Request for Due Process Proceedings

Student Information

• Student's Full Name: _________________________________________________

• School Attending: _________________________________________________

• School Address: _________________________________________________

• Zip Code: _______________

• Date of Current IEP: /________/

• School District Number: _______________

Parent or Legal Guardian Contact Information

• Name: _________________________________________________

• Address (if different from student’s address): _________________________________________________

• City, State: _________________________________________________

• Zip Code: _______________

• Email Address: _________________________________________________

  • ☐ Check here if you prefer to receive notices by email.

• Phone Numbers:

  • ☐ Home: (______) _________________________

  • ☐ Cellular: (______) _________________________

  • ☐ Work: (______) _________________________

  • ☐ Other: (______) _________________________

  • Please check the box next to the preferred contact number. All calls will be made between 8 a.m. and 5 p.m.

• Primary Language in the Home:

  • ☐ English

  • ☐ Other (specify): _________________________

  • ☐ Check here if you need a translator for the proceeding. Specify language: _________________________

  • ☐ Check here if you need a sign language interpreter at the proceeding.

Problem Description and Proposed Solution

1. Description of the Problem:

   • Clearly describe the concerns or disagreement with the school district. Please include specific facts and circumstances.

   • If additional space is needed, attach a separate sheet.

2. Proposed Solution:

   • Provide a detailed explanation of the solution you are proposing to address the issue(s) mentioned above.

   • If additional space is needed, attach a separate sheet.

Signature and Authorization

I certify that the information provided in this request is accurate to the best of my knowledge.

• Signature of Person Completing the Form: _________________________________________________

• Date: /________/

• Relationship to Student:

  • ☐ Parent / Legal Guardian

  • ☐ Attorney

  • ☐ Other (specify): _________________________

  Note: If “Attorney” or “Other” is selected, please provide contact information below. Information on this case will only be discussed with individuals in a parental relationship unless the attorney has submitted a Notice of Appearance, or if “Other,” a confidentiality release form has been signed and submitted by the parent or legal guardian.

Attorney or Other Contact Information (if applicable)

• Name: _________________________________________________

• Telephone: (______) _________________________

• Address: _________________________________________________

• Zip Code: _______________

• Email Address: _________________________________________________

Important Notes

• If your mailing address is different from the student’s school records, please update your information with the school. Filing this form does not automatically update the student’s records.

• Attach all relevant documents that support your request, including a copy of the current IEP, evaluation reports, or communication records with the school district.

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