Mediation Only Request Form

Office of Administrative Hearings OAH Form 63; Revised July 2012Special Education Unit Page 2 of 4Mediation Only Request FormSTUDENT INFORMATION:NAME, First and Last (Required)ADDRESS (Required)_______________________________________________________________________________________________________________DATE OF BIRTHGRADE LEVELSCHOOL OF ATTENDANCE(Required)DISTRICT OF RESIDENCE(Required)____________________________________________________________________________________________________________________________________________________PARENT INFORMATION:NAME, First and Last (Required)ADDRESS (Required)HOME/MESSAGE PHONEWORK PHONEFAXEMAIL ADDRESS__________________________________________________________________________(_____)_______________________________(_____)_______________________________(_____)____________________________________________________________________Interpreter needed? ☐ Yes or ☐No If yes, what language?________________PARTIES TO BE NAMED:DISTRICT OF RESIDENCE_____________________________________(Required)ADDITIONAL PARTIES_____________________________________(Required)(Any other school district, including school of attendance, or public agency that isresponsible for providing services that should be a party in the mediation andhearing.) A copy of this form must be sent to each party you named.