NONPUBLIC, NONSECTARIAN SCHOOL/AGENCY SERVICES
INDIVIDUAL SERVICES AGREEMENT (ISA) FOR NONPUBLIC, NONSECTARIAN SCHOOL SERVICES(Education Code Sections 56365 et seq.)This agreement is effective on FORMTEXT ????? 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, 20 FORMTEXT ??, unless sooner terminated as provided in the Master Contract and by applicable law.Local Education Agency FORMTEXT ?????Nonpublic School FORMTEXT ?????LEA Case Manager: Name FORMTEXT ?????Phone Number FORMTEXT ????? Pupil Name FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Sex: FORMCHECKBOX M FORMCHECKBOX F Grade: FORMTEXT ????? (Last) (First) (M.I.)Address FORMTEXT ?????City FORMTEXT ????? State/Zip FORMTEXT ?????DOB FORMTEXT ????? Residential Setting: FORMCHECKBOX Home FORMCHECKBOX Foster FORMCHECKBOX LCI # FORMTEXT ????? FORMCHECKBOX OTHER FORMTEXT ????? Parent/Guardian FORMTEXT ?????Phone ( FORMTEXT ????? ) FORMTEXT ????? ( FORMTEXT ????? ) FORMTEXT ????? (Residence) (Business)Address FORMTEXT ?????City FORMTEXT ????? State/Zip FORMTEXT ????? (If different from student)AGREEMENT TERMS:Nonpublic School: The average number of minutes in the instructional day will be: FORMTEXT ????? during the regular school year FORMTEXT ????? during the extended school yearNonpublic School: The number of school days in the calendar of the school year are: FORMTEXT ?????during the regular school year FORMTEXT ?????during the extended school year3.Educational services as specified in the IEP shall be provided by the CONTRACTOR and paid at the rates specified below.A. INCLUSIVE AND/OR BASIC EDUCATION PROGRAM RATE: (Applies to nonpublic schools only): Daily Rate: FORMTEXT ?????Estimated Number of Days FORMTEXT ?????x Daily Rate FORMTEXT ?????= PROJECTED BASIC EDUCATION COSTS FORMTEXT ?????B. RELATED SERVICES:ProviderSERVICELEANPSOTHERSpecify# of Times per wk/mo/yr., Duration; or per IEP; or as neededCost per sessionMaximum Number of SessionsEstimated Maximum Total Cost for Contracted PeriodIntensive Individual Services (340) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Language/Speech Therapy (415)a. Individualb. Group FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Adapted Physical Ed. (425) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Health and Nursing: Specialized Physical Health Care (435) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Health and Nursing Services: Other (436) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Assistive Technology Services (445) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Occupational Therapy (450) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Physical Therapy (460) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Individual Counseling (510) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Counseling and guidance (515). FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Parent Counseling (520) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Social Work Services (525) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Psychological Services (530) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Behavior Intervention Services (535) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Specialized Services for Low Incidence Disabilities (610) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Specialized Deaf and Hard of Hearing Services (710) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Interpreter Services (715) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Audiological Services (720) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Specialized Vision Services (725) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Orientation and Mobility (730) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Braille Transcription (735) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Specialized Orthopedic Service (740) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Reader Services (745) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Note Taking Services (750) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Transcription Services (755) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Recreation Services (760) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????College Awareness Preparation (820) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Vocational Assessment, Counseling, Guidance and Career Assessment (830) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Career Awareness (840) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Work Experience Education (850) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Mentoring (860) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Agency Linkages (865) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Travel Training (870) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Transition Services (890) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other (900)J FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other (900) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Transportation-Emergencyb. Transportation-Parent FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Bus Passes FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ESTIMATED MAXIMUM RELATED SERVICES COST$ FORMTEXT ?????TOTAL ESTIMATED MAXIMUM BASIC EDUCATION AND RELATED SERVICES COSTS$ FORMTEXT ?????4. Other Provisions/Attachments: FORMTEXT ?????5. MASTER CONTRACT APPROVED BY THE GOVERNING BOARD ON FORMTEXT ????? 6.Progress Reporting Requirements: QuarterlyMonthlyOther (Specify)The parties hereto have executed this Individual Services Agreement by and through their duly authorized agents or representatives as set forth below.-CONTRACTOR--LEA/SELPA-(Name of Nonpublic School/Agency) (Name of LEA/SELPA)(Signature) (Date)(Signature) (Date)(Name and Title)(Name of Superintendent or Authorized Designee) ................
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