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



Placement Information               

Placement/Facility         

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)



Submit               


























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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