_________________________________
Student Name
Please check the YES boxes only if you agree that the statements are correct. If the statements are not correct, check the NO boxes. When you have finished, please sign and date.
YES _____ NO _____ I have been notified that my child has shown appropriate progress in reading and/or writing in the dyslexic program.
YES _____ NO _____ I do give my permission for my child to be exited from the dyslexic program to the regular reading program.
_________________________________
Signature of Parent or Guardian
________________
Date