Department of Educational Services
Division of Special Education
Request for YMCA Student Membership
Who: Building Principal
Why: To request budget support from special education funds to support YMCA student membership.
When: When the IEP team has determined that YMCA participation is an appropriate student activity.
Action:
Required by School:
¨ The building principal reviews request for YMCA student membership.
¨ The building principal completes the Request for YMCA Student Membership form and forwards to their area/level special education coordinator for recommended approval.
¨ After approval is received, Case Manager completes MMSD Student YMCA Membership Application form and submits membership to YMCA.
¨ Staff person(s) supporting student at the YMCA completes MMSD Attendant Use Form and forwards to special education coordinator and YMCA staff.
¨ Case Manager informs special education coordinator and YMCA if student membership is terminated.
Required by Department/Division:
¨ Special education coordinator reviews requests and indicates their approval/non-approval of request.
¨ Completed form will be distributed to individuals/departments as indicated on form.
¨ Purchasing Secretary reviews monthly invoice for verification of approved memberships.
Note: The Request for YMCA Student Membership form is attached. The completed form may be submitted via school mail or faxed (204-0349).
Department of Educational Services
Division of Special Education
Request for YMCA Student Membership
Student Name: ______DOB: ______
School: ______
Case Manager: ______
YMCA Location: ___ East YMCA ___ West YMCA
The YMCA will be used on (please be as specific as possible):
Beginning Date: ______Ending Date: ______
Days of Week: ______Times: ______
Activities performed by the student will include:
Student will be using the following rooms and equipment at the YMCA:
Additional Comments:
Completed by Principal:
Approved: Not Approved: Signature: ______Date: __-__-__
Completed by Special Education Coordinator:
Approved: Not Approved: Signature: ______Date: __-__-__
Distribution After Approval:
Ø High School Department Chair (via school mail)
Ø Student’s Case Manager (via groupwise)
Ø YMCA Staff (via e-mail)
Ø Purchasing Secretary
DSE-Allocation/Budget (Gold #12a)
08/28/07