ࡱ> '` Wbjbj{P{P C::b       t \/\/\/8/P0,T 1$5:5557"<9<x:SSSSSSS$UhXlS ;77;;S  554MT>>>;@ 5 5S>;S>>N  O5|1 `+Ye\/X;2OOcT0THO:X;X,OX O8>;;;SS>;;;T;;;;d\/\/4$Xp        (To be Completed By LEA) INDIVIDUAL SERVICE AGREEMENT UNDER THE SONOMA COUNTY SPECIAL EDUCATION 2010/11 MASTER CONTRACT FOR NONPUBLIC, NONSECTARIAN SCHOOL/AGENCY SERVICES Name of Local Education Agency:  FORMTEXT       Name of Nonpublic Agency: Kathleen Gusky-Sharp, OTR/L, NPA Pupil s Name: FORMTEXT       SEX:  FORMCHECKBOX M  FORMCHECKBOX F (Last), (First), (Middle) Pupil s I.D./S.S. #:  FORMTEXT       Birthdate:  FORMTEXT       Grade:  FORMTEXT       Residential Setting:  FORMCHECKBOX HOME  FORMCHECKBOX FOSTER  FORMCHECKBOX LCI Foster/LCI Phone:  FORMTEXT       Pupil s Address:  FORMTEXT       LCI/Foster Home License Number:  FORMTEXT       Parent/Guardian s Name:  FORMTEXT       Phone: home  FORMTEXT       work  FORMTEXT       NON-EDUCATIONAL PLACING AGENCY: (If applicable)  FORMTEXT       All terms and conditions of the current Sonoma County Special Education Local Planning Area Master Contract for Nonpublic, Nonsectarian School/Agency Service (NPS/NPA), hereinafter referred to as the  Contract, are incorporated herein by this reference. Contractor will implement the pupils Individualized Education Program (IEP) in accordance with this Individual Service Agreement and the Contract. Invoices shall be submitted based on actual service provided and attendance standards in the Contract. A. BASIC EDUCATION PROGRAM (Applies to Nonpublic schools only) Contractor shall enroll pupil in its Basic Education Program commencing on  FORMTEXT      , and ending on  FORMTEXT      , unless earlier terminated by notice from LEA upon pupil s change of residence, change of placement or termination of the Master Contract. Number of Regular School Days  FORMTEXT      Per Diem N/A = Total Regular School Year Basic Education Costs (Adjusted annually) N/A Number of ESY Days  FORMTEXT    Per Diem N/A = Total ESY Basic Education Costs (Adjusted annually) N/ATotal Instructional Days (Item-D page 2)  FORMTEXT  =b1+b2 00 Total Basic Education Costs -Adjusted annually (Item -A on page 2) N/A INDIVIDUAL PUPIL SPECIFICATIONS (Complete # 2, #5 and #6 or reference IEP) The pupils teacher/service provider will hold the appropriate credential/license to provide such service as issued by California Commission on Teacher Credentialing, Sonoma County Office of Education or the appropriate California Licensing Agency. The class size for the pupil will not exceed 12, or if fewer than 12, specify:  FORMTEXT      . The Related Service therapist/pupil ratio will not exceed  FORMTEXT      . The length and content of the Basic Education Program will be consistent with the Contract unless otherwise specified in the IEP. Contractor shall provide authorized services in accordance with the pupil s IEP & this ISA. Method for complying with statewide standardized assessment requirements:  FORMTEXT       Dates student will not attend NPS per SELPA approved calendar:  FORMTEXT      . 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C. DESIGNATED INSTRUCTION AND SERVICES/RELATED SERVICES: ESTIMATE Pupil s Name Pupil s Name: Service Provided Cost Per Hour as set forth in Master Contract  Estimated Hours until next IEP ESTIMATED TOTAL (Equals Cost Per Hour times (x) Estimated Sessions times (x) Hours per session) FORMTEXT       FORMTEXT       Eligibility  FORMTEXT       MinutesFrequency (times per week/ month/ Year)WK/ Month/ YearStart Date1. Occupational Therapy   FORMTEXT        FORMTEXT     FORMDROPDOWN  FORMTEXT        FORMTEXT $81.69  FORMTEXT        FORMTEXT  =f4*g4 $0.00$0.002.  FORMTEXT         FORMTEXT        FORMTEXT     FORMDROPDOWN  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT  =f5*g5 0$0.00*Maximum DIS and Related Services Cost Estimate(C)Above Estimated Totals  FORMTEXT  =h4+h5 $0.00$0.00*Maximum Total Basic Education Cost Estimate(A) Item A from page 1 N/A*Maximum Total Basic Education and DIS/Related Services Cost Estimate(A + C)  FORMTEXT  =d6 $0.00$0.00Estimated Per Diem  DIS/Related Services divided by instructional daysInstructional Days - Item D from page 1  FORMTEXT     (A + C divided by D)  FORMTEXT  =c8/c9 !Number Too Large To Format     The parties hereto agree to comply with the terms of the Master Contract and hereby execute this Individual Service Agreement by and through their duly authorized agents or representatives. Kathleen Gusky-Sharp, OTR/L, NPALocal Educational Agency  FORMTEXT      ______________________________________________________________________________(Authorized Signature) (Date)(Authorized Signature) (Date)105 Vista View Dr.(Name)  FORMTEXT      Cloverdale, CA 95425 FORMTEXT      (707) 894-7409 phone FORMTEXT      N/A fax(Mailing Address) FORMTEXT       Phone  FORMTEXT       Fax     PAGE 2 10/11 20010/11 Gusky-Sharp ISA Page  PAGE 2 of  NUMPAGES 2 FFFFGGGbGtGvGWW($ )  xHX (#$$Ifa$l ($ )  xHX (#$$Ifa$l *$ )  xHX (#$2$Ifa$l *$ )  xHX (#$2$Ifa$l  vGxGGGGGGzH*$ )  xHX (#$2$Ifa$l ($ )  xHX (#$$Ifa$l % )  xHX (#$$Ifl GGGxHzH|H~HHHHHHHHHHHHHHHHHHHHĴtiĴVLh!CJOJQJ$jh!5CJOJQJUh!5CJOJQJh!5:CJOJQJ)jh!5CJOJQJUmHnHu$j2h!5CJOJQJUh!5CJOJQJjh!5CJOJQJU h!5CJh!56:CJOJQJh!6:CJOJQJh!5:CJOJQJh!56CJOJQJzH|HHH}U**$ )  xHX (#$2$Ifa$l ' )  xHX (#$2$Ifl kd$$Ifl4,rJD%``8`8D%4 lalHHHH*$ )  xHX (#$2$Ifa$l % )  xHX (#$$Ifl ($ )  xHX (#$$Ifa$l HHHHI}UUU' )  xHX (#$2$Ifl kd$$Ifl4rJD%  8 8D%4 lalHHIIIIII(IJZJ\J^J`JbJvJxJzJJJJJ˷˪nWNh!5OJQJ,jh!5:CJOJQJUmHnHu'jh!5:CJOJQJU-jh[h!5:CJOJQJU!jh!5:CJOJQJUh!5:CJOJQJ'jh!5:CJOJQJUh!5:CJOJQJ!jh!5:CJOJQJU,jh!5:CJOJQJUmHnHuJJJJJJJJJJJJJJJJJJJK KKKKK$K&K*K0K򽯽|||q|d|q|Yh!5CJOJQJjOh!5Uh!5mHnHujh!5U h!5%jh!5OJQJUmHnHu jh!5OJQJUjh!5OJQJUh!5OJQJhK V5OJQJmHnHu&j+hK VhK V5OJQJUhK V5OJQJjhK V5OJQJU(K*KXKZKE% )  xHX (#$$Ifl kd$$IflRִ2 JD%888D%    4 lal0K2KFKHKJKTKVKXKZK\K^KrKtKvKKKKKKKKKKKK妕jVjIh!5:CJOJQJ'jyh!5:CJOJQJU,jh!5:CJOJQJUmHnHu'jh!5:CJOJQJU!jh!5:CJOJQJUh!5:CJOJQJh!CJOJQJ)jh!5CJOJQJUmHnHu$jh!5CJOJQJUh!5CJOJQJjh!5CJOJQJUZK\KKKKKKKK L"LJLLLL($ )  xHX (#$$Ifa$l  KKKKKKKKKKKKKKKLLLLL"L$L8L:LMNMPMZM\M^M`MjMlMnMpMrMMMMMMMMNNNNNNNĻİwɝnh!>*OJQJh!6CJOJQJ j-h!5OJQJUh!CJOJQJh!OJQJh!:>*OJQJh!5:OJQJh!:OJQJ h!5h!5OJQJ jh!5OJQJUjh!5OJQJUh!5OJQJmHnHu+LLLG!% )  xHX (#$$Ifl kd$$Iflִ2 JD%888D%    4 lalLL$M&MnM($ )  xHX (#$$Ifa$l ($ )  xHX (#$$Ifa$l ($ )  xHX (#$$Ifa$l nMpMMMMmDm($ )  xHX (#$$Ifa$l % )  xHX (#$$Ifl kkd$$Ifl\JD%88 D%4 lalMMNNAkkd $$Ifl\JD%88D%4 lal($ )  xHX (#$$Ifa$l ($ )  xHX (#$$Ifa$l NNNNNN.Xkd"$$IflFJD%8D%    4 lal($ )  xHX (#$$Ifa$l ($ )  xHX (#$$Ifa$l % )  xHX (#$$Ifl NNNNNNNNNNNNNNNNNOtOvOOOOOOOOOOOOPraN%jh!5OJQJUmHnHu j"h!5OJQJUh!56:CJOJQJh!:CJOJQJh!5:CJOJQJh!6:CJOJQJh!5:OJQJh!5:>*OJQJ h!5 ju!h!5OJQJUh!5OJQJmHnHujh!5OJQJUh!5OJQJh!OJQJNvOOOOO P"PP($ )  xHX (#$$Ifa$l ($ )  xHX (#$$Ifa$l % )  xHX (#$$Ifl OOPP P"P$P8P:PJPLPPPPPPPPPRR\R^RRRRRRRRRRָ֥䕋zvhWh!je%h!CJOJQJUjh!CJOJQJUh! 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