ࡱ> '` dqbjbj{P{P G::fT :2:2:28r23d6L\ 4XN;:;;;c<@>L?;[=[=[=[=[=[=[$l]h_la[@c<c<@@a[;;\QEQEQE@(;;;[QE@;[QEQE+UV;4 <:2@UOV\0L\U:@`SA@`,V@`V0QE@@@a[a[AE@@@L\@@@@666:2666:2$  (To be Completed By LEA) INDIVIDUAL SERVICE AGREEMENT UNDER THE SONOMA COUNTY SPECIAL EDUCATION 2010/2011 MASTER CONTRACT FOR NONPUBLIC, NONSECTARIAN SCHOOL/AGENCY SERVICES Name of Local Education Agency:  FORMTEXT       Name of Nonpublic School: Larry M. Simmons High School 3632 LCI 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  FORMTEXT $181.57 = Total Regular School Year Basic Education Costs (Adjusted annually)  FORMTEXT  =b1*d1 $0.00$0.00 Number of ESY Days  FORMTEXT     Per Diem  FORMTEXT $181.57 = Total ESY Basic Education Costs (Adjusted annually)  FORMTEXT  =b2*d2 $0.00$0.00Partial Day Student Number of Regular School Days FORMTEXT    Per Minute FORMTEXT $.50Number of minutes per day FORMTEXT     = Partial Day Student Total Regular School Year Basic Education Costs (Adjusted Annually) FORMTEXT  =(d3*f3)*b3 $0.00$0.00Partial Day Student Number of ESY Days FORMTEXT    Per Minute FORMTEXT $.50Number of minutes per day FORMTEXT     = Partial Day Student Total ESY Basic Education Costs (Adjusted Annually) FORMTEXT  =(f4*d4)*b4 $0.00$0.00Total Instructional Days (Item-D page 2) FORMTEXT  =b1+b2+b3+b4 00Total Basic Education Costs -Adjusted annually (Item -A on page 2) FORMTEXT  =f1+f2+h3+h4 $0.00$0.00 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. 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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, Miles or Sessions 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. Speech FORMTEXT       FORMTEXT    FORMDROPDOWN  FORMTEXT      Included in 3632 LCI Tuition Daily Rate FORMTEXT       FORMTEXT  =f4*g4 0$0.002. Temporary Behavioral Support Assistant FORMTEXT       FORMTEXT    FORMDROPDOWN  FORMTEXT      Included in 3632 LCI Tuition Daily Rate FORMTEXT       FORMTEXT  =f5*g5 0$0.003. Transportation  home to school FORMTEXT       FORMTEXT    FORMDROPDOWN  FORMTEXT      Included in 3632 LCI Tuition Daily Rate FORMTEXT       FORMTEXT  =f6*g6 0$0.004.  FORMTEXT       FORMTEXT       FORMTEXT    FORMDROPDOWN  FORMTEXT       FORMTEXT $0.00 FORMTEXT       FORMTEXT  =f7*g7 $0.00$0.00*Maximum DIS and Related Services Cost Estimate(C)Above Estimated Totals  FORMTEXT  =h4+h5+h6+h7 $0.00$0.00*Maximum Total Basic Education Cost Estimate(A) Item A from page 1  FORMTEXT      *Maximum Total Basic Education and DIS/Related Services Cost Estimate(A + C)  FORMTEXT  =d8+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  =c10/c11 !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. Family Life CenterLocal Educational Agency  FORMTEXT      ________________________________________________________________________(Authorized Signature) (Date)(Authorized Signature) (Date)365 Kuck Lane(Name) FORMTEXT      Petaluma, CA 95472 FORMTEXT      (707) 795-6954 phone FORMTEXT      (707) 769-4072 fax(Mailing Address) FORMTEXT       Phone  FORMTEXT       Fax     PAGE 2 10/11 2010/11 L Simmons 3632 LCI ISA Page  PAGE 1 of  NUMPAGES 2 \]]] ] ]]]]^X^Z^\^^^^^___ynaTF? h|5CJh|56:CJOJQJh|6:CJOJQJh|56CJOJQJh|5CJOJQJh|5:CJOJQJh|:CJOJQJh|5:CJOJQJh|5:CJOJQJh|5CJOJQJ h|5CJh|h&FOCJOJQJh&FO5>*CJOJQJ!jh&FO5>*CJOJQJU,jh&FO5>*CJOJQJUmHnHu]]]]F^X^Z^\^p^^^\% )  xHX (#$$Ifl ($ )  xHX (#$$Ifa$l ($ )  xHX (#$$Ifa$l *$ )  xHX (#$2$Ifa$l  ^^^__Rkd=$$Ifl4,rQr$`!``TD%4 la*$ )  xHX (#$2$Ifa$l ______________________````尣~tftUfA&jh|CJOJQJUmHnHu!jmh|CJOJQJUjh|CJOJQJUh|CJOJQJ$jh|5CJOJQJU h|5CJh|5CJOJQJh|5:CJOJQJh|5:CJOJQJ)jh|5CJOJQJUmHnHu$jXh|5CJOJQJUh|5CJOJQJjh|5CJOJQJU______]2*$ )  xHX (#$2$Ifa$l % )  xHX (#$$Ifl ($ )  xHX (#$$Ifa$l *$ )  xHX (#$2$Ifa$l ' )  xHX (#$2$Ifl ____"`}UUU' )  xHX (#$2$Ifl kd$$Ifl4rQr$ !  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