SD Associates Summer 2020 Contract Request

    Student name*

    Person filling out this form*

    Your Email*

    School District*


    Remote Learning*

    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.)


    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.)


    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*