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               
First Name
Last Name
Date of Birth   (mm/dd/yyyy)
Gender
Ethnicity
SIS ID
Status


Student Languages       show more           (check all that apply)   





Resident School District       select         
  No District selected


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



Placement Information               

Please enter the information regarding the placement information of the student. Enter educational and residential information as necessary.


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         

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
Zip Code



Residential Placement

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


Placement Type         

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
Zip Code



Requestor Information               

Requestor
Title
First Name
Last Name

Telephone (include Area Code)
Email
Requestor Address     




Request Information               

Request Type
Name of Surrogate Parent Requested (optional)



Additional Information               




Submit               

Notifications of appointment or withdrawal will be sent to the requestor as well as any other contact associated with the student in the student information system including, but not limited to, the resident district, cooperative, and facility contact.



























Have questions or need help?  Contact ISBE Special Education: (217) 782-5589 between 8:00am - 5:00pm, Monday - Friday or Click Here to Contact Us
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