Request for IEP Meeting and Request for ESY
Date: 
Delivered by: ☐ Email ☐Fax ☐ U.S. Mail 
To Special Education Director:
School District: 
District Address:
Email: 
Re:
Date of Birth: 
Name of School: 
Grade: 
Dear Director of Special Education:
I am concerned my child has not received an appropriate education or equal access to their education during remote and/or hybrid instruction. My child has regressed and I worry they will regress further over the summer. I write to request special education instruction and related services during Extended School Year (ESY) for my child. I am also writing to request an IEP meeting to be held within 30 days. 
My child has experienced challenges and regression during remote instruction. (describe) 
I request that you send me a prior written notice of the school district’s decision and the reasons for any decision, if the district decides to deny my request. I look forward to meeting with you to discuss my child’s IEP.
Sincerely, 
Signed:

Parent/Guardian/Educational Rights Holder name:
Address:
Telephone:
Email: 
*Keep a copy for your own records