FORM 29 INDIVIDUAL SERVICE PLAN FOR PARENTALLY PLACED PRIVATE SCHOOL STUDENTS

 

1.      Student Name: Enter the students last name and first name.

 

2.      DOB: Enter the students 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 students 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 students 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 districts 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 districts 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]