JV-537 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS: ATTORNEY FOR (Name): FAX NO.: SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: CHILD'S NAME: CASE NUMBER: EDUCATIONAL RIGHTS HOLDER STATEMENT To the educational rights holder: Before each scheduled review hearing, you must do one or more of the following: (1) provide information and recommendations to the assigned social worker or probation officer, (2) make written recommendations to the court, or (3) attend the hearing and participate in those parts of the hearing that concern the child's education or developmental services. This optional form may assist you in making written recommendations to the court. Please type or print clearly in ink and submit the form well in advance of the hearing but no later than five court days before the hearing. Please provide five additional copies to the clerk. If you need more space to respond, please attach additional pages and check item 13. has not, on the current Order Designating Educational Rights Holder (form JV-535), prohibited disclosure has The court of the information on this form to the parent(s) or guardian(s) of the child or youth named above. 1. a. b. c. d. 2. a. b. c. d. e. f. Child's or youth's date of birth: Age: School (unless confidential): Grade level: Name of educational rights holder: Address: Telephone number: Relationship to child or youth: I was appointed on (date): I was appointed by (name): (1) Local educational agency in (school district): (2) Juvenile court in (county): (3) Other (specify): I am resigning from my appointment. g. 3. Since my appointment, or since my last statement to the court, I have performed the following actions on behalf of the child or youth (specify): 4. I have learned or acquired the following information since the last court hearing (e.g., re: educational progress, placement, school discipline): 5. Based on my observations of the child's physical, emotional, mental, and social development, I believe the child or youth (0­3 years old) may need early intervention services. a. may have a disability or developmental delay (explain): b. 6. The child or youth has the following disabilities or developmental delays (specify): Page 1 of 2 Form Approved for Optional Use Judicial Council of California JV-537 [Rev. January 1, 2014] EDUCATIONAL RIGHTS HOLDER STATEMENT Cal. Rules of Court, rule 5.650 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com JV-537 CHILD'S NAME: CASE NUMBER: 7. The child or youth has the following educational or developmental-services needs because (specify): 8. The child or youth requires the following services to meet his or her educational or developmental needs (specify): 9. The child or youth is receiving the following educational or developmental services or accommodations (explain): a. These services or accommodations are are not appropriate because (explain): b. Date of most recent individualized education program (IEP), section 504 plan, individualized family service plan (IFSP), or individual program plan (IPP): 10. I made a request for assessments from the On (date): a. regional center (name): b. local educational agency (name): c. other (name): 11. a. Type of assessments requested (check all that apply): IEP (1) (2) Section 504 plan (3) IFSP IPP (4) (5) Educationally related mental health services assessments Psycho-educational assessment (6) (7) Other (specify): b. Reason requested (specify): 12. Agency or regional center response: 13. I need more space to respond to item(s) Number of pages attached: and have attached additional pages. Date: (TYPE OR PRINT NAME) (SIGNATURE OF EDUCATIONAL RIGHTS HOLDER) JV-537 [Rev. January 1, 2014] EDUCATIONAL RIGHTS HOLDER STATEMENT Page 2 of 2