appmt

Appendix VIII

Request for Appointment of Surrogate Parent

1. Student's Name: _________________________________________

DOB:________________

Address: __________________________________________ Phone:_________________________________________________

Name of: __________________________________ foster parent(s)

__________________________________ house parents or

__________________________________ other (please

specify relationship)

2. Is student a state ward? Yes___ No___ If NO, go to question #4. Student welfare status code:_____

3. Please identify the student's social worker, regional office, and phone number and go to question #5.

Name:______________________________ Office:____________________ Phone #:_____________

4. Are the student's parents unknown or can they not be located? Please explain and attach documentation of efforts to locate.

Please identify the student's (a) school, principal, teacher(s) or (b) regional CDS site, site coordinator, and case manager:
School:_____________________________________Address:_____________________________

Principal:___________________________________

Phone#:_____________________________

Teacher(s):__________________________________

(b) CDS

Site:___________________________________Address:_____________________________

CDSCoordinator:_____________________________Phone#:_________________________

CDS Case Manager:___________________________

7. Last school system student

attended:____________________________________________

8. Please identify the student's current programming and/or placement:

___referred to PET/ECT only ___resource room

___composite classroom

___self-contained classroom ___public special day school

___private day school ___residential treatment center

___home/hospital bound ___day care

___no programming ___other -(identify)

9. Identify any special considerations for appointing a surrogate parent (e.g., Alternative Communication System, Foreign Language, Minority Group).

10. Can you recommend any individual that could serve as this student's surrogate parent?

Name:______________________________________

Relationship to Student:_________________________

Address:___________________________________________________________________________

Telephone #:____________________

11. Individual making referral:________________________________________________________

Title:________________________________ Phone #:__________________ Date:_________________

Please return to: Department of Education

Surrogate Parent Program

23 State House Station

Augusta, ME 04333

Tel: 624-6650

FAX 624-6651