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 S^D 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.