Extended School Year Services 2016-17
Deadline for all entries April 28, 2017

1. Extended School Year/Compensatory Services

THIS IS NOT THE FORM TO USE IF YOU ARE REGISTERING A STUDENT FOR SPEECH ONLY

Question Title

* 1. Home School - This is not the form to use if you are registering a speech only student.

Question Title

* 2. Student's Last Name

Question Title

* 3. Students's First Name

Question Title

* 4. Primary Exceptionality

Question Title

* 5. Date of Birth(mm/dd/yyyy)

Question Title

* 6. Age

Question Title

* 7. Grade

Question Title

* 8. Parent's Name

Question Title

* 9. Parent/Guardian's Address

Question Title

* 10. City

Question Title

* 11. Zip:

Question Title

* 12. Home Phone / Cell Phone/Work Phone

Home:

Cell:

Work:

Question Title

* 13. Summer Address - #, Street, City, and zip code (only if different from school year address):

Question Title

* 14. Will this student be attending the summer program for Compensatory Education Services or extended school year? Select only one.

Question Title

* 15. If you selected Compensatory check the services that apply:

Behavior

Academics

Speech

Question Title

* 16. Special transportation needs identified in the student's 2016-17 IEP.

Wheel Chair

Parent will transport with contract (with prior approval ONLY)

Parent will transport

Seatbelt required

Needs to be on a bus with air conditioning

Needs to be on a bus with a nurse

Needs to be on a bus with an aide

Other (please specify)

Question Title

* 17. Does this student have a record in Behavior 360? If the answer is yes, please attach a copy of the record to the IEP when sending the paperwork for ESY. ALL BIP'S SHOULD BE ATTACHED IN SETS.

Yes

Question Title

* 18. Justification for ESY:

Question Title

* 19. Was ESY documentation given to and approved by your Special Education Resource Teacher?

Question Title

* 20. Indicate Medical Needs and/or Special Equipment such as: Diastat, Inhaler, Seizure magnet, Feeding tube, Trach, Special Diet Instructions, Allergies to food/materials, Stander, Special Chairs, Communication Devices, Stroller, etc.

The following person attended the IEP meeting. Please sign and date.

Parent ____________________________________________Date________
LEA_______________________________________________Date________
Special Ed Teacher __________________________________Date_________
General Ed Teacher__________________________________Date________
Other Agency ______________________________________Date________

THE PARENT(S) WILL RECEIVE A LETTER NOTIFYING THEM OF THE ESY SITE.

Question Title

* 21. Remember to print out this form and have the IEP team members sign. Click on file, print preview and then select 60%, and print. User may print out only the pages that apply to student's ESY. Dont forget to click on "Submit" after printing.

I have read these directions.