Individual Service Plan for Parentally Placed Private School Students (29)
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Student name
,
D.O.B.
Grade
Date
Date
Date
Parent/Guardian name(s)
Address
,
City
Zip
Home phone
Cell
Work phone
District where private school is located
District of residence
-
Home school
Private school
Private school phone
District of residence phone
Check one of the following
Student's parents have declined the district's offer of a Service Plan.
Student's parents have accepted the district's offer of a Service Plan.
Services: The District (LEA) will provide the special education service(s) below for the student while enrolled in private school or until the proportionate share of federal funds have been expended for the current school year.
Area(s) of need
Summary of present levels
Assistive technology and/or services
Special education service
Frequency
Duration
Location
Start date
End date
Service provider
Check
Check
Check
Check
Check
Check
Student has been found eligible for special education services.
By signing this document, the parent/guardian(s) have indicated to the District of Residence (DOR) that they have chosen to unilaterally enroll or continue to enroll the student in a private school without the consent of, referral by, or at expense of the District. It is further acknowledged that the DOR has offered to develop an IEP when the student's parent/guardian(s) express an interest in enrolling the student in public school. The parents understand in accordance with IDEA 2004, their rights to due process do not apply in the private school setting.
Parent/Guardian
Date
Parent/Guardian
Date
LEA Representative
Date
Other
Date
Next annual review due by
Triennial review due by