Individual Service Plan for Parentally Placed Private School Students (29)
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Student's name ,   D.O.B.   Grade   Date Date Date Pick a 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 Pick a date Check Pick a date
Check Pick a date Check Pick a date
Check Pick a date Check Pick a date
 

 
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