Summer Contract Request / Change Form (ESY)

Welcome to the SD Associates Summer 2021 Contract Request for Northern Vermont School and Clinic-Based Services. If you’re interested in FUV services, please email: windsor.admin@sdplus.org

Please fill out all fields in the form below. If you have questions, you can leave them in the last box titled ‘Additional notes’. After submitting, a director will be in touch within one business day to answer any questions and confirm the fulfillment of your request.

Student name*

Person filling out this form*

Your Email*

School District*

Dates of service (Reminder: a minimum contract is 20 days and no services available on the following dates: July 1, 2, 9, 16, 23, 30 - August 6, 9, 10, 11, 12, 13, 20)

June:

July:

August:

List direct service hours below

• Half day is 3.5 to 4 hrs between 8 - 12pm or 12:30-4:30pm

• Full day is 7 to 7.5 hrs between 8 – 4:30pm

Half day:

OR
Full day:

Additional services requested that will be itemized outside of the daily rate.

1.5:1 BI coverage needed as outlined in IEP*

2:1 BI coverage needed as outlined in IEP*

Direct services of Special Educator or SLP for students served in our locations. We will not be providing services for students not served in our locations or remotely.

Mins per day of direct special educator (SE)* (this will be billed in addition to the 1 hr per week of SE included in the daily rate - this will be consult)

Mins per day of direct speech/language pathologist (SLP)* (this will be billed in addition to the 1 hr of week of SE included in the daily rate - this will be consult)

Location:

Is transportation needed to and from program?* (This time will be within the contracted day.)
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/SLP, 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 Sept. 1, 2021.

I understand that the following is included in the daily rate: behavioral instructor (BI), behavior analyst (BA), special educator and SLP as needed. Transportation can occur within the timeline of services and mileage will be billed at the federal rate. Additional costs will only occur for the following: special educator consultation services if more than 1 hours are needed per week; SLP services if more than 1 hour is needed per week; if a student requires more than a 1:1 ratio for staffing.

Signature (Please type your name below to electronically sign this form)*

Date Signed*

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