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Transition of Children At Age Three Appendix E SAMPLE FORM NAME OF COUNTY - EARLY INTERVENTION PROGRAM CONSENT FORM FOR TRANSMITTAL OF EIP EVALUATIONS AND RECORDS TO THE CPSE DATE Child s Name Last EI First Phone No. Name of Parent/Legal Guardian Home Address School District Service Coordinator Early Intervention Official/Designee CPSE Chair Please Read I understand that the CPSE may use evaluation reports and other EIP records which I may choose.

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