Form 24782t - Certification Of Iep/ifsp Prior To Enrollment -Riverside County Division Of Children And Family Services

Download a blank fillable Form 24782t - Certification Of Iep/ifsp Prior To Enrollment -Riverside County Division Of Children And Family Services in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 24782t - Certification Of Iep/ifsp Prior To Enrollment -Riverside County Division Of Children And Family Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Division of Children and Family Services
Early Childhood Education Programs
Certification of IEP/IFSP Prior to Enrollment
I. Educational Information: Complete this form only for children who have a valid IEP or IFSP prior to enrollment.
Today’s Date: _____________ Site: _______________________________ Community Assistant: ___________________________
Child’s Name: _______________________ Date of Birth: __________________________ Child Plus ID#: __________________
 I certify that the above named child has a valid IEP or IFSP prior to enrollment: _______________________________________
Disabilities PDS Signature
II. Income Information: Complete this section to verify possible use of over-income slots for child with an IEP or IFSP .
Enter the actual family income % based on the FPL at time of recruitment in the blank box which best corresponds:
Income between 0% - 100% of FPL
End here - No additional approval required for eligibility.
0%
Income between 101-399% of FPL
End here - No additional approval required for eligibility.
0%
Income at 400% or above of FPL
Continue Below - Additional approval is required for eligibility.
0%
III. Over-Income Waiver Rationale - Complete this section only if the family income is at or above 400% of the FPL.
The family of this child is requesting enrollment for this child based on the following additional criteria:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
For Grantee Use Only
Based on the additional information, Enrollment for this family has been:  Approved
 Disapproved
Executive Director Name: _____________________________ Signature: ________________________ Date: _____________
ERSEA Coordinator Name: ____________________________ Signature: ________________________ Date: _____________
Disabilities PDS Name: _______________________________ Signature: ________________________ Date: _____________
Form No. 24782T (Revised 09/15)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go