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Request for Yuba County SELPA Alternate Dispute Resolution Services
Please fill out this form to the best of your ability. If you need assistance in completing this form, please call (530) 749-4873 or email
lora.gonzalez@yubacoe.k12.ca.us
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* Indicates required question
Your Name
*
Your answer
Name of the Student
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Your answer
Student Date of Birth
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MM
/
DD
/
YYYY
Relationship to the Student
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Parent/Legal Guardian
School District
School
Other:
Primary Laguage Parent/Legal Guardian
English
Spanish
Hmong
Other:
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What is the best phone number to reach you?
*
Your answer
What is the best email to reach you?
Your answer
Where is the child/student enrolled for school?
Choose
Camptonville Union Elementary School District
California Montessori Project - Capitol Campus
California Montessori Project - Elk Grove
California Montessori Project - San Juan Campuses
California Montessori Project - Shingle Springs
Marysville Joint Unified School District
Plumas Lake Elementary School District
Wheatland School District
Wheatland Union High School District
Yuba County Office of Education
Student's School of Attendance
*
Your answer
What is the SSID for this student? If you don't have it, please type N/A.
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Your answer
Is this the first request for ADR services through Yuba County SELPA for this student?
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Yes
No
Other:
What concerns do you have that prompted a request for ADR support through the Yuba County SELPA?
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Lack of educational progress
Services not delivered consistent with student's IEP
Quality of virtual services
Poor communication from school
Other:
Required
If this is not your first request for ADR services, what steps have taken place to come to an agreement as a team?
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IEP meeting
Meeting with school administrator
Meeting with district level administrator or support person
Meeting/Collaboration with a Family Resource Center (e.g., Family Soup, etc.)
Other:
Required
Please share your concerns in more details
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Your answer
What other steps have you and the team taken to resolve these concerns and/or disagreements?
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Your answer
What would be your desired outcome?
*
Your answer
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