SD Associates Summer 2020 Contract Request Student name* Person filling out this form* Your Email* School District* Option* —Please choose an option—123 Remote Learning* —Please choose an option—YesNo Additional services requested that will be itemized outside of the daily rate. List direct service hours below if needed outside of the embedded 2-hour consult of SE and 1 hour of SLP. 1.5 or 2:1 BI coverage needed as outlined in IEP* Hours per day of Special Educator (SE)* Hours per day of Speech Language Pathologist (SLP)* Is transportation needed to and from program?* (This time will be within the contracted day.) YesNo Can we offer supplemental services to this student?* (Supplemental services are any days that we have staff available outside of the scheduled ESY time that can be offered free of charge.) YesNo Additional Comments* By signing this form, I'm stating that I understand that the school district's related service providers and/or SD Special Educator / Speech Language Pathologist (depending on who was responsible for IEP goals in the school year) will provide materials and Teaching Learning Plans for IEP work throughout the service time. A progress report will be sent out to the IEP team by September 1, 2020. Signature / School District (Please type your name below to electronically sign this form)* Date Signed* Please leave this field empty.