Mediation Request (Parent)

Mediation Request Form (Parent)

Complete Section I by explaining the disagreement with the school district or agency.
Complete Section II by reading each of the statements. For mediation to take place, both the parent/guardian and the school district/agency must agree to these statements.
Complete Section III by typing in the requested information about parent/guardian and the name of the school district.
Forms will not be accepted without the signature of the parent/guardian or the person requesting the mediation.
Fill in the date that you are making your request for mediation.

You can get additional information by calling the Office of Special Education Services at 803-734-8224, or the Office of General Counsel at 803-734-8783, or going to the Department of Education's Web site at: http://www.ed.sc.gov.

Section I (Please print or type.)

Student's Name*

First Name

Middle Name (optional)

Last Name

Suffix (optional)

We are requesting that a mediator approved by the South Carolina Department of Education be named to help us work out the following disagreement:

Section II

• We reviewed the procedures for mediation in special education in South Carolina and understand that it is a voluntary process and not a requirement.

• We agree to meet to work out our differences in a way acceptable to each of us and in the best interest of the student.

• We understand that the student’s current placement remains the same. We understand that by agreeing to mediation, neither the school district/agency nor the parent/guardian gives up the right to a due process hearing or to file a formal complaint.

• We understand that mediation is confidential and agree not to require the mediator to be a part of any future due process hearing or court proceeding. We understand that when a resolution is reached during mediation, the parties must execute a written legally binding agreement that is enforceable in any state or federal court. We understand that whatever is said or happens during mediation cannot be used in a future due process hearing or court proceeding.

Section III (Please print or type.)

Name of school district/agency:

Address of school district/agency:

Address Line 1

Address Line 2

City

State

ZIP Code

Phone of school district/agency:

Date of Request or Agreement to Participate in Mediation:

Name of parent/guardian:

First Name

Last Name

Address of parent/guardian:

Address Line 1

Address Line 2

City

State

ZIP Code

Phone of parent/guardian:

Email of parent/guardian:

Signature of parent/guardian:

[clear]

Use your mouse or finger to draw your signature above