Child-Specific Exception
Application
Submit original plus 1 copy (including documentation if needed)
Student Name: __________________________________________
Date of Birth: __________________________________________
Parents Daytime Phone: ________________________________
Parents Email: _______________________________________
Period of Request (not to exceed one year): From: ________ To: ___________
Date application was submitted: _____________________
Describe the requested exception:
Explain why the student will benefit from this exception?
Describe any psychological or health issues (e.g. hearing or vision impairment, medications, mobility limitations, medical diagnoses or restrictions) that are relevant to this request.
Suggested documentation to accompany application for behavioral exceptions:
Student’s current IEP
Proof of student's disability and diagnoses from appropriate certified or licensed professionals including reports summarizing testing performed and results
Student’s most recent and relevant prior behavioral assessments
Any proposed, current and/or prior behavioral intervention plans, including documentation of the implementation and progress monitoring of the effectiveness of such plans
Other relevant individual evaluations and medical information that allow for an assessment of the student’s cognitive and adaptive abilities and general health status
Information from the child’s parent (if available from the parent)
Attach
and identify additional documents that are related to this request
1. Identify accompanying documents that provide documentation of the positive
effect of the strategy that you are requesting as it has been tried in
other
educational environments: including documentation of the implementation and
progress monitoring of the effectiveness of such strategies.
2. Identify and explain any supportive documents or recommendations from professionals in fields related to this request
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