Individual Service Plan (Isp) - Parentally Placed Private School Students - State Selpa Iep Template
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1STATE SELPA IEP TEMPLATE
INDIVIDUAL SERVICE PLAN (ISP) - PARENTALLY PLACED PRIVATE SCHOOL STUDENTS
Student Name _____________________
Date of Birth ___/___/________
ISP Date ___/___/________
Grade
_____________________
Parent / Guardian _________________________________
Home Phone
_________________________________
Home Address
_________________________________
Work Phone
_________________________________
City
_________________________________
Cell Phone
_________________________________
State, Zip
_________________________________
Email
_________________________________
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.
OR
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 _____________________________________________________________________________________
Special Education
Frequency
Duration
Location
Start Date
End Date
Service Provider
Service
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
Surrogate
Adult Student
Date ____/_____ /____
Parent _______________________________________________
Date ____/_____ /____
LEA Representative _____________________________________
Date ____/_____ /____
Other ________________________________________________
Date ____/_____ /____
Next Annual Review Due By ____/_____ /____
Triennial Review Due By ____/_____ /____
Revised 07/2013
Form 29
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