VERIFICATION OF RECEIPT OF THE EARLY START DUE PROCESS
AND FAIR HEARING PROCEDURE AND THE PARENTS RIGHTS
AND RESPONSIBILITIES IN THE EARLY START PROGRAM
I have received a copy of the Early Start Due Process and Fair Hearing Procedure.
_______________________________________ ___________________
Consumer, Parents, Conservator or Guardian Date
I have received a copy of the “Parents Rights and Responsibilities in the Early Start Program.”
_______________________________________ ___________________
Consumer, Parents, Conservator or Guardian Date
Consumer Name:____________________________________
DOB:______________________________________________
UCI Number:________________________________________
click to sign
signature
click to edit
click to sign
signature
click to edit