Individual Service(s) Plan For Voluntarily Enrolled Private School Students

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  Date* Date*  
 
       

Student Name   DOB DOB   Age   Gender Gender
 
     

Social Security # Social Security #   ID Code ID Code   CSIS Code   Current Grade Current Grade
 
   

Name of Parent/Surrogate Guardian   Ph: Home Ph: Home   Ph: Work Ph: Work
 
       

Address   Apt. #   City     Zip
 
     
       

District of Residence District of Residence   School School   Private School Enrolled in Private School Enrolled in  
 
   

Home Language Home Language   Student's Language  
 
Migrant Ed
Ethnicity

1 1   2 2

3 3   4 4

5 5   6 6
English Language Learner
Interpreter Required
DATES

Initial Placement in Special Ed. Initial Placement in Special Ed.
Last Triennial Last Triennial
Next ISP Next ISP
 
PURPOSE OF MEETING* PURPOSE OF MEETING*

 
AGENCY SERVICES

 
 
 
 
  Other agency services (specify):  
 
RESIDENCY RESIDENCY

Other type:
Foster/LCI#.

Pursuant to 20 U.S. C. 1412(a)(10)(IDEA 97) and 34 C.F.R. 300.450 et. seq. and the NCCSE policy, special education and related services will be provided to the student while enrolled in private school as set forth below:

Special education & Related Services pursuant to NCCSE Policy #19 Program Modifications/Support for Private School Personnel (Consultative Services) Frequency of Service Duration Location Start Date End Date
(check date) (check date)
(check date) (check date)

Primary Disability Category Primary Disability Category
 
Present Levels of Educational Performance




*Denotes items that are always required