Illinois State Board of Education (ISBE), Special Education Services Division

EDUCATIONAL SURROGATE PARENT ELECTRONIC REQUEST FORM

Please fill out this form as completely as possible.  Note that some fields are required.

● = Required field.

Student Information               

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First Name	●
Last Name	●
Date of Birth	(mm/dd/yyyy) ●
Gender	Select... Female Male Non-Binary ●
Ethnicity	Select... American Indian or Alaska Native Asian Black or African American Hispanic or Latino Middle Eastern or Northern African Native Hawaiian or Other Pacific Islander Two or More Races Unknown White ●
SIS ID
Status	Select... Student has an IEP Student's evaluation in progress (IEP only) Student has 504 Plan ●

Request Information               

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Request Type	Select... Appointment Replacement Withdrawal ●
Name of Surrogate Parent Requested (optional)

Student Languages       show more           (check all that apply)    ●

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English	Arabic	German	Korean	Russian
American Sign Language	Cantonese (Chinese)	Italian	Mandarin (Chinese)	Tagalog (Filipino)
Spanish	French	Japanese	Polish	Vietnamese

Resident School District       select          ●

If the student is attending school in the home district, please indicate the name of the school if known.

Placement Information               

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Please provide details regarding the student’s current educational and residential placement.

**Important** When submitting a withdrawal request, the student’s placement information should be entered as it was at the time they were enrolled in the facility or district submitting the request.

Educational Placement (Required)

Educational Placement means the facility at which student is currently or will be attending school and/or receiving educational services.

Placement Type      Select... Residential Public District Other     ●

Placement/Facility Name (if your facility has more than one program, please specify) ●

Telephone (include Area Code) ● Email

Address Line 1 ● Address Line 2 Suite/Apt. City ● State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ● Zip Code ●

Residential Placement (Required)

Residential Placement means any transitional or temporary living environment such as a group home, shelter, hospital, and/or transitional living.

Placement Type      Select... Transitional Living Other Hospital Group Home     ●

Placement/Facility Name (if your facility has more than one program, please specify) ●

Telephone (include Area Code) ● Email

Address Line 1 ● Address Line 2 Suite/Apt. City ● State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ● Zip Code ●

Requestor Information               

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Requestor	Select... Residential Placement School District Other ●
Title	●
First Name	●
Last Name	●

Telephone (include Area Code) ● Email ●

Requestor Address      Select... Same as Placement Different from Placement ●

Additional Information               

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Submit               

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Notification of appointment or withdrawal will be sent to the requestor, the Educational Surrogate Parent, and all relevant contacts associated with the student in the system. This includes, but is not limited to, the resident district, special education cooperative, and residential facility.

Please note: It is the responsibility of the requesting agency, facility, or district to ensure that a withdrawal request is submitted when a student is no longer eligible for an Educational Surrogate Parent (ESP).

Please be aware that the requestor’s information will be included on the appointment letter.