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Sample Service Agreement
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Sample Service Agreement 

Attachment to Basic Education Circular
SUBJECT:  Implementation of Chapter 15
         22 Pa. Code Chapter 15

DATE OF ISSUE:  July 1, 1999
DATE OF EXPIRATION:  June 30, 2004


Student Name: __________________________________

Date Services Begin: ______________________________

Date Services End: ________________________________

Initial Agreement: _________________________________

Modified Agreement: ______________________________

I am writing as a follow-up on our recent evaluation concerning your child and to summarize our recommendations and agreements for aids, services or accommodations. The aids, services or accommodations are as follows:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

The following procedures need to be followed in the event of a medical emergency:

______________________________________________________________________
______________________________________________________________________

The attached letter outlines your rights to resolve any disputes that you may have concerning the recommended aids, services or accommodations. If you have any questions concerning your rights or the aids, services or accommodations recommended, please feel free to contact me.

________________________ ________________________
School District Administrator Date

DIRECTIONS: Please check one of the options and sign this form.

_____ I agree and give permission to proceed as recommended.

_____ I do not agree and do not give permission to proceed as recommended.

_____ I would like to schedule an informal conference to discuss my concerns.

My reason for disapproval is: ____________________________________________
_______________________________________________________________________

________________________ ________________________
Parent(s) Signature Date

July 1, 1999 -- 22 Pa. Code Chapter 15