FORM
29 INDIVIDUAL SERVICE PLAN
FOR PARENTALLY
PLACED PRIVATE SCHOOL STUDENTS
1. Student Name: Enter the student’s last
name and first name.
2. DOB: Enter
the
student’s date of birth.
3. Grade: Enter
the
student’s current grade level.
4. Date: Enter
the
date.
5. Parent / Guardian/Surrogate
Names: Enter the name(s) of
the
parent(s), guardian(s) or surrogate.
6. Address: Enter
the
student’s current address. If
the
student is living in a residential school,
enter the address of
the
parent.
7. Home Phone: Enter
the
phone number of
the
parent(s) or guardian(s).
8. Cell Phone: Enter
the
cell number of the parent(s) or guardian(s), if
known.
9. Work Phone: Enter
the
work phone of one of the parent(s) or guardian(s),
if
known.
10. District where private school
is
located: Enter
the
name of the district where the private school is located (unless other agreements have been made.
This would be the district
drafting and implementing the Service Plan.
11. District
of residence: Enter the name of the district where the student’s parent(s)
or guardian(s) reside.
12. Home School: Enter
the
name of the school the student would attend if they were living at
the
address of their parent(s) or guardian(s) and not attending a private school.
13. Private School: Enter
the name of the private school where the student is currently attending.
14. Private School
Phone: Enter the phone number of the private school.
15. District
of Residence Phone: Enter
the
phone number of the District of Residence listed on the Service Plan (item
10
above).
16. Check the following: Check ONLY one
of the following:
Student’s parent(s), guardian(s),
surrogate or the adult student
have declined the district’s offer of a Service Plan – check this option if the parent(s) or
guardian(s) have declined wanting a service plan.
This would be applicable if they want no services or if at some time they choose
to enroll the student
in
a public school program in the district of
residence.
Student’s parent(s), guardian(s),
surrogate or the adult student
have accepted the
district’s offer of a Service Plan.
16. Services: Enter
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.
17. Area(s) or need:
Enter the area(s)
of
need based on the assessment results.
18. Summary
of Present Levels: Enter
the
present levels in relevant areas assessed
(social /
emotional,
academic, etc.).
19. Enter the service(s): Enter
the
service(s) being offered.
Remember,
the
services offered
must be based on the final decisions the SELPA / District
have
made with respect to private school services. (§300.320)
20. Frequency: Enter how often the service will
take place or how many sessions, etc.
21. Duration: Enter
how long (minutes, hours, etc.) each service will
take place.
22. Location: Enter
the
location where services will
take place.
23. Start
Date:
Enter the date when services will
begin.
24. End Date:
Enter the date when services will end.
25. Service Provider: Enter the “title,” not
the
name, of the service provider.
26. Signature Lines: Parent(s), guardian(s), surrogate or the adult student
have the parent/guardian/surrogate or adult
student sign in attendance.
LEA Representative – enter
the
name of the person who is representing the district / LEA.
Remember this person must have the authority to allocate services.
Other – have any other persons in attendance sign the Service Plan.
27. Next Annual Review Due By: Enter the next annual
review date (approximately one year from the date of the date of the current service plan meeting).
28. Triennial Review Due By: Enter the triennial
review date. This is three years from the date of the last assessment
review or the initial assessment
review
[Excerpted from the State SELPA IEP Manual, July, 2013]