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Educational Representation Or Surrogate Parent Information Form. This is a California form and can be use in Juvenile Judicial Council.
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Tags: Educational Representation Or Surrogate Parent Information, JV-537, California Judicial Council, Juvenile
JV-537
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
FOR COURT USE ONLY
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CHILD'S NAME:
EDUCATIONAL REPRESENTATIVE OR
SURROGATE PARENT INFORMATION
CASE NUMBER:
To the educational representative or surrogate parent of the child: You may submit written information to the court or to the
child's social worker or probation officer, and you may attend review hearings. This optional form may assist you in providing written
information to the court. Please type or print clearly in ink and submit the form well in advance of the hearing but no later than seven
days prior to the hearing. Please provide five additional copies to the clerk.
1. a.
b.
c.
d.
Child's date of birth:
Child's age:
Child's school:
Child's grade level:
2. a.
b.
c.
d.
e.
Name of educational representative or surrogate parent:
Address:
Telephone:
I was appointed as educational representative or surrogate parent on (date):
I was appointed as educational representative or surrogate parent by (name):
(1)
Local education agency in (school district):
(2)
Juvenile court in (county):
(3)
Other (specify):
f.
I am resigning from my appointment.
3. Since my appointment as educational representative or surrogate parent, or since my last form JV-537 statement, I have
performed the following actions on behalf of the child (specify):
4.
I do not have any new or additional information since the last court hearing.
5.
I have new or additional information since the last court hearing (e.g., changed school, school discipline):
6.
Based on my observations of the child's physical, emotional, mental, and social development, I believe the child
(0–3 years old) may be eligible for early intervention services.
a.
may have a disability (explain):
b.
7.
The child has the following disabilities (specify):
8.
The child has the following educational needs (specify):
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Form Approved for Optional Use
Judicial Council of California
JV-537 [New January 1, 2008]
EDUCATIONAL REPRESENTATIVE OR
SURROGATE PARENT INFORMATION
Cal. Rules of Court, rule 5.650
www.courtinfo.ca.gov
American LegalNet, Inc.
www.FormsWorkflow.com
JV-537
CHILD'S NAME:
CASE NUMBER:
9.
The child requires the following services to meet his or her educational needs (specify):
10.
The child is receiving the following education-related services or accommodations (explain):
a. These services or accommodations
are
are not appropriate (explain):
b. Date of most recent individualized education plan (IEP) or section 504 plan:
11.
On (date):
I made a request for assessments from the
a.
regional center (name):
b.
local education agency (name):
c.
other (name):
12. a. Type of assessments requested (check all that apply):
Individualized education plan
(1)
Section 504 plan
(2)
(3)
Individual family plan
AB 3632 county mental health assessments
(4)
Psycho-educational assessment
(5)
Other (specify):
(6)
b. Reason requested (specify):
13.
If you need more space to respond to any section above, please check this box and attach additional pages.
Number of pages attached:
Date:
(TYPE OR PRINT NAME)
JV-537 [New January 1, 2008]
(SIGNATURE OF EDUCATIONAL REPRESENTATIVE OR SURROGATE PARENT )
EDUCATIONAL REPRESENTATIVE OR
SURROGATE PARENT INFORMATION
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