Reference Number

AGREEMENT TO MEDIATE

We, the undersigned, have been fully informed of the mediation process and agree to abide by the procedures and guidelines governing the process, and that:

1. The mediator is a specially trained impartial third party whose role is to assist us in making mutually determined decisions regarding the appropriate special education services or placement for:

               ______________________________________________________________________________________

                                                                                          (Name of Student)

2.     The mediator is not serving as a legal representative, counselor, or advocate and will not make decisions regarding the special education services or placement to be provided to the student.

3.     The mediator cannot be called upon as a witness or consultant in any other administrative, judicial, or educational process. Mediation discussions are confidential. Any recording (electronic or otherwise) of a mediation session is not permitted. The only written record will be the agreement that we jointly develop and agree upon in the mediation process; and

4.     Participation in a mediation session is voluntary, and mediation may not be used to delay or waive the parties' right to proceed with a due process hearing.

5.    Kansas Law, at K.S.A. 72-996, requires that any agreement reached by the parties to this mediation must be in writing and signed by the parent and an authorized representative of the school district. The law also requires that, at a minimum, every mediation agreement must include the following statements:

          1) the resolution of each issue presented in the complaint;

          2) all discussions that occurred during the mediation process are confidential and may not be used as

              evidence in any subsequent due process hearing or civil proceeding; and

          3) each party understands that the agreement is legally binding upon them; and

          4) the agreement may be enforced in state or federal court.

6.    If this mediation includes complaint issues currently under investigation by the Kansas State Department of Education, we agree that the timelines for completion of that investigation shall be extended to provide us with an opportunity to complete the mediation process.

Parent:                                              

^Signature

Date:             

^{Type or Print Name}

Education Agency

Representative:                               

^Signature

Date:             

^{Type or Print Name}

^{Please FAX and mail to:                                              Mediation Consultant, Student Support Services}

                                                                                          ^{KS State Dept. of Education}

                                                                                          ^{120 SE Tenth Avenue; Topeka, KS 66612-1182}

                                                                                          ^{Phone:  (800) 203-9462 or (785) 296-5478}

                                                                                          ^{FAX: (785) 296-6715}