Individual Service Contract for Nonpublic, Nonsectarian School/Agency Services

Individual Service Contract for Nonpublic, Nonsectarian School/Agency Services

INDIVIDUAL SERVICES AGREEMENT FOR NONPUBLIC, NONSECTARIAN SCHOOL/AGENCY SERVICES

(Education Code Sections 56365 et seq.)

This agreement is effective on ______or the date student begins attending a nonpublic school or receiving services from a nonpublic agency,

if after the date identified, and terminates at 5:00 P.M. on June 30, 200__, unless sooner terminated as provided in the Master Contract and by applicable law.

Local Education Agency: Nonpublic School/Agency:

LEA Case Manager: Name Phone Number

Pupil Name: Sex: ( ) M ( ) F Grade:

(Last) (First) (M.I.)

Address City State/Zip

DOB: SSID#Residential Setting: ( ) Home ( ) Foster ( ) OTHER

Parent/GuardianPhone ( ) ( )

(Residence) (Business)

Address City State/Zip

(If different from student)

AGREEMENT TERMS:

  1. Education Schedule – Regular School YearCalendar Provided:YesNo
  1. Education Schedule – Extended School YearCalendar Provided:YesNo

3. Educational services as specified in the IEP shall be provided by the CONTRACTOR and paid at the rates specified below.

EDUCATION PROGRAM: (Applies to nonpublic schools only): Daily Rate: ______

Estimated Number of Days______x Daily Rate ______= PROJECTED BASIC EDUCATION COSTS (A)

  1. DESIGNATED INSTRUCTION AND SERVICES / RELATED SERVICES:

Provider
SERVICE / LEA / NPS / NPA / OTHER
Specify / # of Times per wk/mo/yr., Duration;
or per IEP. / Cost per session / Maximum Number of Sessions / Estimated Maximum Total Cost for Contracted Period
1. Behavior Intervention
a. Individual
b. Group
c.Other
  1. Supervision to include:

  1. Consultation to include:

  1. Transportation

  1. Mileage

  1. Other

  1. Other

ESTIMATED MAXIMUM RELATED SERVICES COST (C)$

C. SPECIALIZED EQUIPMENT/SUPPLIES $

TOTAL ESTIMATED MAXIMUM BASIC EDUCATION/ RELATED SERVICES

COSTS/SPECIALIZED EQUIPMENT/SUPPLIES (A, B & C) . $

4. Other Provisions/Attachments: ______

INDIVIDUAL SERVICES AGREEMENT APPROVED BY CASE MANAGER:

(Signature) (Date)

MASTER CONTRACT APPROVED BY THE GOVERNING BOARD ON

The parties hereto have executed this ISA by and through their duly authorized agents or representatives as set forth below. By execution of this ISA, CONTRACTOR and LEA agree to the terms and conditions of the 2015-16Shasta County SELPA Nonpublic Nonsectarian Agency Service Master Contract (“Master Contract”). This ISA is not intended to impose upon LEA any obligations in addition to those imposed by federal and state laws and regulations. Neither the Master Contract nor this ISA shall confer third party beneficiary status upon any other person, including but not limited to, any student and/or parent.

The parties hereto have executed this Individual Services Agreement by and through their duly authorized agents or representatives as set forth below.

-CONTRACTOR- / -DISTRICT-
(Name of Nonpublic School/Agency) / (Name of School District)
(Signature) (Date) / (Signature) (Date)
(Name and Title) / (Name of Superintendent or Authorized Designee)

Shasta SELPA ISA, Behavior Intervention, 8-15

Top View