SLC’s Education Request Form

This complaint form is designed to assist us in the evaluation of your legal problem. When filling out this form, please be as specific and detailed as possible. It is important that all questions be answered fully and completely.

Unfortunately, our resources are limited. We take cases that raise significant issues and which have the potential to impact others in the same situation. We cannot take all cases offered us, even those concerning real injustices. If we do not accept your case, it does not mean it is without merit.

If we need further information, we have your address and/or telephone number and can request any documents necessary.

We will be respond to your request within 30 days of receipt. If you do not hear from us within 30 days, please contact us.

SUBMISSION OF THIS COMPLAINT FORM AND REQUESTS YOU MAY RECEIVE FROM US FOR FURTHER INFORMATION, OR DISCUSSIONS WE MAY HAVE WITH YOU, INCLUDING PROVIDING PRELIMINARY SUGGESTIONS REGARDING THE POSSIBLE RESOLUTION OF YOUR COMPLAINT, DOES NOT CONSTITUTE ACCEPTANCE OF YOUR CASE AND THE FORMATION OF AN ATTORNEY/CLIENT RELATIONSHIP.

Although we keep our files confidential, submitting cases via the Internet is not a secure means of transmission. If you do not wish to submit your form via the Internet, you may download the PDF version of this form, complete the form, print and mail it to the postal address below.

1. Information about you - Name (first last): *
Relationship to Child: *
Address: *
City: *
State: *	----Not ApplicableAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip Code: *
County:
Daytime Telephone: *
Evening Telephone:
E-mail:
2. Information about the child - Child's Name: *
Child's Date of Birth: *
Child's School:
Child's Current Grade:
Does the school system identify the child as an exceptional education student?	Yes  No
If so, when was the child identified?
If so, what is the child’s identified exceptionality?
List any other disabilities the child has and approximate date of diagnosis:
Does the child receive special education services?	Yes  No
When was the most recent testing done by the school board?
Was the child’s placement or individual education plan changed as the result of the testing?	Yes  No
Has there been any testing done by someone outside of the school?	Yes  No
If yes, who did it and when?
Acadmic performance:	Excellent  Very Good  Good  Poor  Very Poor
Does the child have behavioral problems at school?	Yes  No
Does the child have behavioral problems at home?	Yes  No
Has the child been promoted yearly?	Yes  No
Any suspensions or expulsions from School?	Yes  No
Is the child on any medications?	Yes  No
What medications?
Is medication taken at school?	Yes  No
3. Describe your complaint. Be as specific as you can.:
4. Have you filed for a due process hearing?	Yes  No
If yes, when?
5. Have you filed a complaint with the Department of Education?	Yes  No
If yes, when?
6. Are you represented by an attorney in this matter?	Yes  No
If yes, what is the Attorney’s name:
Attorney’s Address:
Attorney’s City:
Attorney’s State:	----Not ApplicableAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Attorney's Zip Code:
Attorney's County:
Attorney's Telephone:
7. Please send us by mail the following documents, if available:	(1) The latest IEP  (2) The latest school board and/or independent evaluation(s)  (3) Any complaint you may have filed  (4) Any letters you may have written to any school board personnel expressing your complaints/concerns
8. Please state specifically what you would like SLC to do for you:
9. How did you hear about SLC?
10. Household Income. SLC receives grants to represent low income persons. Sometimes we take cases even if you are not considered "low income." Please fill out this information even if you think you do not qualify for "low income."
How many people live in your house? Include yourself and others.
What is the gross income from a job or self-employment for everyone living in the house for either:
Monthly?
Yearly?
Does anyone living in the house receive government benefits? (list Who and How much a month is received)
Do you have significant medical or child care expenses? Amount:
How much cash do you have in checking and savings?
What is the approximate value of the other things you own? Do NOT include anything in the following list.
Value:
For the Question above - Do NOT include anything in the following list.	Homestead property being used as the principal place of residence;  Vehicles which are necessary for household transportation and employment;  Personal and household effects;  Trust for medical expenses;  Value of farm land essential to employment or self employment;  Work related equipment needed for employment of a family member provided its owner is producing income or attempting to produce income with it;  Cash value of IRAs, TSAs or KEOGH Plans;  Assets that are excluded under the Food Stamps, TANF, and SSI programs;  Educational grants and loans to pay for tuitions and fees;  Any assets which are not easily convertible to cash or which are not legally or practically available to the individual or family unit;  Incentive allowances under any federal or state training program;  Any assistance paid with respect to a dwelling unit under the United States Housing Act of 1937;  Any assistance received on account of major disaster;  Jointly held assets when establishing the eligibility of a victim of domestic violence.
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