Equitable Participation Evaluation Request Form - Private School Students
This form is to be completed to make known a child with a potential disability who may need to be evaluated under the Individual with Disabilities Education Act (IDEA).  Once we receive this completed Request Form, the parent/legal guardian of the child will be contacted for permission to evaluate the child.
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Email *
INDIVIDUAL MAKING EVALUATION REQUEST *
Please indicate who is completing the form. 

NOTE: if selecting the parent / guardian option below,  you must have legally valid parental rights or be a LEGALLY APPOINTED guardian.
Nonpublic School Name: *
Please enter the school where the student is enrolled
Student First Name *
Student Last Name *
Student Date of Birth *
MM
/
DD
/
YYYY
Student Gender *
If the student identifies as non-binary, please select non-binary IN ADDITION TO the sex indicated on the student's birth certificate. When submitting information to the PA State Department of Education, SDP/IU 26 will be able to note that a student identifies as non-binary, but the state is required to record and display the information from the legal birth certificate. We continue to advocate for similar changes to be adopted at the state and federal levels.
Required
Student Race *
Student CURRENT Grade *
Student must be at least kindergarten aged and either homeschooled (through formal arrangement) or enrolled in a private elementary or secondary school. Students enrolled in stand alone day care centers are NOT eligible for this program. 
Address  Where Child Resides (Street, City, Zip) *
FULL ADDRESS including City and Zip Code are REQUIRED. Failure to provide this may result in delays.
What is the primary language spoken in the home?
 *
Does the parent and/or student require translation or interpretation? If so, please specify and include the language.
 *
Please provide a brief summary to explain why you are concerned that the student may have a disability that is hindering their educational progress.   *
Are there concerns related to additional functional areas? i.e. concerns around speech development, motor skills, physical development, etc.?
 *
Has the student been evaluated for special education and/or the current area of concern?
 *
If so, what was the result / eligibility determination?
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