ࡱ> '` zibjbj{P{P C::bc       t$<7<7<78t7h8T_ 9x?:???@ B<C^^^^^^^$`hFcl^ D@@DD^  ??x_IIID ? ?^ID^IIX  Y?9 zp<7DYZ_0_Y:cEEc,Yc Y0IDDD^^IDDD_DDDD <7<74$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: On Our Own, Inc. 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 pupils IEP & this ISA. Method for complying with statewide standardized assessment requirements:  FORMTEXT       Dates student will not attend NPS per SELPA approved calendar:  FORMTEXT      . Other Provisions:  FORMTEXT      . 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       Mi24nV X  " < > @ T V X b d h r t ϹϨp\p'jvhU5>*CJOJQJU,jhU5>*CJOJQJUmHnHu'jhU5>*CJOJQJUhU5>*CJOJQJ!jhU5>*CJOJQJUhS75CJOJQJhU5CJOJQJhU5CJOJQJhU>*CJOJQJhU5OJQJhUOJQJhUCJOJQJ4nX $ 8 h$ ) 8 xHX (#$a$$ 8 $a$ $ $@&a$  8 $@&$ ) 8 xHX (#$dh@&a$$ ) 8 xHX (#$a$$ ) 8 xHX (#$@&a$ hxit v 8 ` d f z | ~ 癌xa癌Ma'jJhU5>*CJOJQJU,jhU5>*CJOJQJUmHnHu'jhU5>*CJOJQJUhU5>*CJOJQJ!jhU5>*CJOJQJUhUCJOJQJ'j`h[`hUCJOJQJUhU5CJOJQJ'jh[`hUCJOJQJUhUCJOJQJjhUCJOJQJU     D F b d f p t v  Ͷڟ}iU'jh[`hUCJOJQJU'jh[`hUCJOJQJU'j6h[`hUCJOJQJUjhUCJOJQJU,jhU5>*CJOJQJUmHnHu-jhMehU5>*CJOJQJUhU5>*CJOJQJ!jhU5>*CJOJQJUhU5CJOJQJhUCJOJQJ8  $ 6nyoT$ ) 8 xHX (#$a$ $ $$a$ $@& # 8 xH$@&$ # 8 xH$dha$$ # 8 xH$@&a$$ 8 xH$dha$$ & 8 xHX $dha$    " D F H \ ^ ` j l  06z|׶ממk׫מW׶'jhU5>*CJOJQJU'j~hU5>*CJOJQJUhU>*CJOJQJ'jhU5>*CJOJQJUhU5>*CJOJQJhU5CJOJQJhUCJOJQJ,jhU5>*CJOJQJUmHnHu!jhU5>*CJOJQJU-jhMehU5>*CJOJQJU"(*,68<FH\^`jlnη۠Ή۠~sbUAb'jVhU5>*CJOJQJUhU5>*CJOJQJ!jhU5>*CJOJQJUhU5CJOJQJhU5CJOJQJ-jhMehU5>*CJOJQJU,jhU5>*CJOJQJUmHnHu-jjhMehU5>*CJOJQJUhU5>*CJOJQJ!jhU5>*CJOJQJUhUCJOJQJhUCJOJQJ(*p  ",.0NPdfhrtĹΒu`WΒE`#jBhU5>*OJQJUhU>*OJQJ(jhU5>*OJQJUmHnHu#jhU5>*OJQJUhU5>*OJQJjhU5>*OJQJUhU6CJOJQJhU56CJOJQJhU5CJOJQJhUB*CJphhUCJOJQJ!jhU5>*CJOJQJU,jhU5>*CJOJQJUmHnHur$@&Ifl ($ ) 8 xHX (#$$Ifa$l $ ) 8 xHX (#$a$$ )  xHX (#$a$  ABFG_apqrsڧڧچڧڝzni\jhU56CJU hU5hU6B*CJphhU5B*CJph%j hU5B*CJUphhUhUB*CJphhUB*CJph*jhU5B*CJUmHnHphu%jhU5B*CJUphhU5B*CJphjhU5B*CJUphhU5B*ph"F($ ) 8 xHX (#$$Ifa$l kd" $$Iflֈ~ N <$F T04 lal  ABF$@&Ifl ($ ) 8 xHX (#$$Ifa$l  FGaqF % ) 8 xHX (#$$Ifl kd $$Iflֈ~ N <$F T04 lalqr$@&Ifl ($ ) 8 xHX (#$$Ifa$l $$@&Ifa$l $@&Ifl s}~%&ȼȲuaQhS7hS75>*CJOJQJ'jhS7hS75>*CJOJQJUhS7hS7>*CJOJQJhS7hS7CJOJQJhU56OJQJhUOJQJhUB*CJph hU6hUB*CJphhU5B*CJphhUjv hU56CJUhU56CJmHnHujhU56CJUhU56CJ&@lQE$!$ & F )  xHX (#$a$gdS7 $ & F`a$$ ) 8 xHX (#$a$kd $$Ifl\~ <$T04 lal|~  6JԺԪԪԺԪԪoԺԝԪXԺԪ-j+hS7hS75>*CJOJQJU-j hS7hS75>*CJOJQJU-j? hS7hS75>*CJOJQJUhS7hS7CJOJQJhS7hS75>*CJOJQJ2jhS7hS75>*CJOJQJUmHnHu'jhS7hS75>*CJOJQJU-j hS7hS75>*CJOJQJU@V iii*$ )  xHX (#$2$Ifa$l $ ) * xHX (#$a$ & F $gdS7 & F , xHJX (#$gdS7!$ & F )  xHX (#$a$gdS7  XZ\|«ґreZMBeZ5hU56CJOJQJhU5CJOJQJhU5:CJOJQJhU:CJOJQJhU5:CJOJQJhU5:CJOJQJhU5CJOJQJ hU5CJ2jhS7hS75>*CJOJQJUmHnHu-jhS7hS75>*CJOJQJUhS7hS75>*CJOJQJ'jhS7hS75>*CJOJQJUhS7hS7CJOJQJhS7hS7CJOJQJFXZ\p\% )  xHX (#$$Ifl ($ )  xHX (#$$Ifa$l ($ )  xHX (#$$Ifa$l *$ )  xHX (#$2$Ifa$l  ^`Rkd$$Ifl4,r5 >$``1`D%4 la*$ )  xHX (#$2$Ifa$l \^`bvxzvcYKYjhUCJOJQJUhUCJOJQJ$jhU5CJOJQJUhU5CJOJQJhU5:CJOJQJ)jhU5CJOJQJUmHnHu$j@hU5CJOJQJUhU5CJOJQJjhU5CJOJQJU hU5CJhU56:CJOJQJhU6:CJOJQJhU5:CJOJQJ`]2*$ )  xHX (#$2$Ifa$l % )  xHX (#$$Ifl ($ )  xHX (#$$Ifa$l *$ )  xHX (#$2$Ifa$l ' )  xHX (#$2$Ifl }UUU' )  xHX (#$2$Ifl kd$$Ifl4r5 >$  1 D%4 la V V V\VdVnVVVVVVVVVWWWµzobQb=Q'j[hU5:CJOJQJU!jhU5:CJOJQJUhU5:CJOJQJhU5CJOJQJ hU5CJhU5CJOJQJhU5:CJOJQJhU6:CJOJQJhU5:CJOJQJUhU5:CJOJQJhUCJOJQJ&jhUCJOJQJUmHnHujhUCJOJQJU!jchUCJOJQJU V V\VrV|VVX*$ )  xHX (#$2$Ifa$l ' )  xHX (#$2$Ifl *$ )  xHX (#$2$Ifa$l ($ )  xHX (#$$Ifa$l nutesFrequency (times per week/ month/ Year)WK/ Month/ YearStart Date1. Temporary Support Behavior Assistant  FORMTEXT        FORMTEXT     FORMDROPDOWN   FORMTEXT        FORMTEXT $26.71  FORMTEXT        FORMTEXT  =f4*g4 $0.00$0.002. Behavior Intervention Plan Development and Modification  FORMTEXT        FORMTEXT     FORMDROPDOWN   FORMTEXT        FORMTEXT $74.66  FORMTEXT        FORMTEXT  =f5*g5 $0.00$0.003. Psychology Services (other than assessment and IEP Development)   FORMTEXT        FORMTEXT     FORMDROPDOWN   FORMTEXT        FORMTEXT $80.39  FORMTEXT        FORMTEXT  =f6*g6 $0.00$0.004. Counseling and Guidance Services (includes parent counseling)   FORMTEXT        FORMTEXT     FORMDROPDOWN   FORMTEXT        FORMTEXT $68.93  FORMTEXT        FORMTEXT  =f7*g7 $0.00$0.005.Behavior Expertise as required by legal cases  FORMTEXT        FORMTEXT     FORMDROPDOWN   FORMTEXT        FORMTEXT $97.62  FORMTEXT        FORMTEXT  =f8*g8 $0.00$0.00*Maximum DIS and Related Services Cost Estimate(C)Above Estimated Totals  FORMTEXT  =h4+h5+h6+h7+h8 $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  =d9 $0.00$0.00Estimated Per Diem  DIS/Related Services divided by instructional daysInstructional Days - Item D from page 1  FORMTEXT     (A + C divided by D)  FORMTEXT  =c11/c12 !Number Too Large To Format     The parties hereto agree to comply with the terms of the Master Contract and hereby execute this Individual Service Agreement by and through their duly authorized agents or representatives. Our Own, Inc.Local Educational Agency  FORMTEXT      ________________________________________________________________________(Authorized Signature) (Date)(Authorized Signature) (Date)1000 Ohio St.(Name)  FORMTEXT      Vallejo, CA 94590 FORMTEXT      (707) 645-8499 phone FORMTEXT      (707) 645-8587 fax(Mailing Address) FORMTEXT       Phone  FORMTEXT       Fax     PAGE 2 10/11 2009/2010 On Our Own ISA Page  PAGE 2 of  NUMPAGES 2 VVVV*$ )  xHX (#$2$Ifa$l % )  xHX (#$$Ifl ($ )  xHX (#$$Ifa$l VVVD% ) h xHX (#$$Ifl kd$$Ifl4lִ5  >$#> 1 D%    4 laVVWW:WWZW\W^WbWdWxWzW|WWWWW˷˪nWNhU5OJQJ,jhU5:CJOJQJUmHnHu'jhU5:CJOJQJU-jGh[`hU5:CJOJQJU!jhU5:CJOJQJUhU5:CJOJQJ'jhU5:CJOJQJUhU5:CJOJQJ!jhU5:CJOJQJU,jhU5:CJOJQJUmHnHuWWWWWWWWWWWWWWWWWWW X XXXXX&X(X*X򽭢zuibibiUiFiUibjhU5CJUhU5CJmHnHu hU5CJjhU5CJU hU5)jhU5CJOJQJUmHnHu$j hU5CJOJQJUhU5CJOJQJjhU5CJOJQJUhU5OJQJhu5OJQJmHnHu&jchuhu5OJQJUhu5OJQJjhu5OJQJU*X,XXE% ) h xHX (#$$Ifl kd1$$IflRִ5  >$#>1D%    4 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