ࡱ> '` 8bjbj{P{P G::r4:::8;\n<j >VtF:FFFGhIdUKhhhhhhh$:khml#i LGG L L#iFFiQQQ LFFhQ LhQQabF> >?O:%Lybb i0jb:nL2n,bnb(Q L L L#i#iQ L L Lj L L L L"::$  (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: North Valley Schools, Inc. Santa Rosa  Hearing LCI 3632 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        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. No payment for any absences. Number of Regular School Days  FORMTEXT       Per Diem  FORMTEXT $169.35 = Total Regular School Year Basic Education Costs (Adjusted annually)  FORMTEXT  =b1*d1 $0.00$0.00 Number of ESY Days  FORMTEXT      Per Diem  FORMTEXT $169.35 = 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 $.47Number 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 $.47Number 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$0.00 INDIVIDUAL PUPIL SPECIFICATIONS (Complete # 2, #5 and #6 or reference IEP) The pupils teacher/service provider will hold the appropriate credential/license to provide such service as issued by California Commission on Teacher Credentialing, Sonoma County Office of Education or the appropriate California Licensing Agency. The class size for the pupil will not exceed 12, or if fewer than 12, specify:  FORMTEXT      . The Related Service therapist/pupil ratio will not exceed  FORMTEXT      . The length and content of the Basic Education Program will be consistent with the Contract unless otherwise specified in the IEP. Contractor shall provide authorized services in accordance with the pupil s IEP & this ISA. Method for complying with statewide standardized assessment requirements:  FORMTEXT       Dates student will not attend NPS per SELPA approved calendar:  FORMTEXT      . Other Provisions:  FORMTEXT      . C. DESIGNATED INSTRUCTION AND SERVICES/RELATED SERVICES: ESTIMATE Pupils Name Pupils Name: Service Provided Cost Per Hour as set forth in Master Contract  Estimated Hours, Miles or Sessions until next IEP ESTIMATED TOTAL (Equals Cost Per Hour times (x) Estimated Sessions times (x) Hours per session) FORMTEXT 24nZ \ L ϹϨpeTGha5>*CJOJQJ!jha5>*CJOJQJUha5CJOJQJ,jha5>*CJOJQJUmHnHu'jha5>*CJOJQJUha5>*CJOJQJ!jha5>*CJOJQJUhMf5CJOJQJha5CJOJQJha5CJOJQJha>*CJOJQJha5OJQJhaOJQJhaCJOJQJ4n\ n  d z^$ & 8 xHX $dha$$ ) 8 xHX (#$a$ $@&  8 $@&$ ) 8 xHX (#$dh@&a$$ ) 8 xHX (#$a$$ ) 8 xHX (#$@&a$ R6    ڹxnaMڹ'jha5>*CJOJQJUha5>*CJOJQJhaCJOJQJ'j`hG3haCJOJQJU'jhG3haCJOJQJUjhaCJOJQJUha5CJOJQJhaCJOJQJ,jha5>*CJOJQJUmHnHu!jha5>*CJOJQJU'jvha5>*CJOJQJU     . < > R T V ` b d  ؋}i}}U}}'jhG3haCJOJQJU'j6hG3haCJOJQJUjhaCJOJQJU-jhdha5>*CJOJQJUha5CJOJQJ,jha5>*CJOJQJUmHnHu'jJha5>*CJOJQJUha5>*CJOJQJ!jha5>*CJOJQJUhaCJOJQJ   F H \ ^ ` j l fhx~|h]|]|F-j~hdha5>*CJOJQJUha>*CJOJQJ'jha5>*CJOJQJUhaCJOJQJ,jha5>*CJOJQJUmHnHu-jhdha5>*CJOJQJUha5>*CJOJQJ!jha5>*CJOJQJUha5CJOJQJjhaCJOJQJU'jhG3haCJOJQJUd n ~l23sqV$ ) 8 xHX (#$a$$ )  xHX (#$a$$ ) 8 xHX (#$a$ $ $$a$ $@& # 8 xH$dh # 8 xH$@&$ 8 xH$dha$ .02<>@JNXZnpr|~̸ٗ̀ٗi^ٗha5CJOJQJ-jhdha5>*CJOJQJU-jjhdha5>*CJOJQJUhaCJOJQJ,jha5>*CJOJQJUmHnHu'jha5>*CJOJQJUha5>*CJOJQJhaCJOJQJha5CJOJQJ!jha5>*CJOJQJU ,.0:<BDFZ\^hjl23NOrsvk^SB!jha5>*CJOJQJUha6CJOJQJha56CJOJQJha5CJOJQJhaB*CJphhaCJOJQJhaCJOJQJ'jha5>*CJOJQJUhdha5CJOJQJ,jha5>*CJOJQJUmHnHu'jVha5>*CJOJQJUha5>*CJOJQJ!jha5>*CJOJQJU  ,.BDFPRηάpYOC3Cjha5B*CJUphha5B*CJphhaB*CJph,jha5>*CJOJQJUmHnHu'jha5>*CJOJQJUha5>*CJOJQJ!jha5>*CJOJQJUhaCJOJQJha>*CJOJQJ,jha5>*CJOJQJUmHnHu!jha5>*CJOJQJU'jBha5>*CJOJQJUha5>*CJOJQJ "$PR($@&Ifl ($ ) 8 xHX (#$$Ifa$l    "$&:<>LNP ٷq`VLFLFL haCJjhaCJUhaB*CJph!hMf5B*CJmHnHphu+j hMfhMf5B*CJUphhMf5B*CJphjhMf5B*CJUphhaB*CJphhaB*CJphha5B*CJph*jha5B*CJUmHnHphujha5B*CJUph+j. hdha5B*CJUph $&(*RTVjlnvxzͳ{qaU?a+j- hMfhMf5B*CJUphhMf5B*CJphjhMf5B*CJUphhaB*CJph*jha5B*CJUmHnHphu+j hdha5B*CJUphha5B*CJphjha5B*CJUphhaB*CJphhaB*CJph haCJj haCJUjhaCJUhaCJmHnHu(*,RF($ ) 8 xHX (#$$Ifa$l kd $$Iflֈ~ X %*F04 lalRTz|*,t$@&Ifl ($ ) 8 xHX (#$$Ifa$l  *,.BDTV`bdfprtv0ʾʾpZPhaB*CJph*jha5B*CJUmHnHphu+j@hdha5B*CJUphjha5B*CJUphj haCJUhaCJmHnHu haCJjhaCJUha5B*CJphhaB*CJphhaB*CJphjhMf5B*CJUph!hMf5B*CJmHnHphutvF($ ) 8 xHX (#$$Ifa$l kdQ $$Iflֈ~ X %*F04 lal@tvPR($ ) 8 xHX (#$$Ifa$l  024<>@tvxPRThjټټن|rk_k_k_R_C_Rjha5CJUha5CJmHnHujha5CJU ha5CJhaB*CJphhaB*CJph*jha5B*CJUmHnHphu+jhdha5B*CJUphhaB*CJphha5B*CJph!ha5B*CJmHnHphujha5B*CJUph+jhdha5B*CJUph 246JLNVXZ%ĘގxgQĘ+j'hdha5B*CJUph!ha5B*CJmHnHphu+jhdha5B*CJUphhaB*CJph*jha5B*CJUmHnHphu+jKhdha5B*CJUphjha5B*CJUphhaB*CJphhaB*CJphha5B*CJphjha5CJU kd0$$Iflִ~  X %*~ F0    4 lal24Z%&O($ ) 8 xHX (#$$Ifa$l  %&'12?@EFGHMNOPhjyz{ĺĺĺwwwjhaCJU haCJ ha6jVha5CJU ha5hahaB*CJphha5B*CJphhaB*CJphha5B*CJphjha5CJUha5CJmHnHujha5CJU ha5CJ*OP kd;$$Iflִ~  X %*~ F0    4 lalPjz $@&Ifl ($ ) 8 xHX (#$$Ifa$l $$@&Ifa$l % ) 8 xHX (#$$Ifl     /XYDFZ\^hjlnvlUHhQMphMfCJOJQJ,jhMf5>*CJOJQJUmHnHu-jeh8hMf5>*CJOJQJUhMf5>*CJOJQJ!jhMf5>*CJOJQJUhMf>*CJOJQJhMfCJOJQJha56OJQJhaOJQJhahaB*CJph haCJjhaCJUjhaCJUhaCJmHnHu  Yn jh\;;;!$ & F )  xHX (#$a$gdMf $ & F`a$kd$$Iflu\~ X %~ 0F04 lalv  ^"`"t"v"x"""""# ## #"#,#.#0#2#X#Z#ϸߞχߞpߞf\K!jhMf5>*CJOJQJUhMfCJOJQJhMfCJOJQJ-jhPfDhMf5>*CJOJQJU-jQhPfDhMf5>*CJOJQJU2jhPfDhMf5>*CJOJQJUmHnHu-jhPfDhMf5>*CJOJQJUhPfDhMf5>*CJOJQJ'jhPfDhMf5>*CJOJQJUhPfDhMfCJOJQJ !!"2##$%$&$'$iii*$ )  xHX (#$2$Ifa$l $ ) * xHX (#$a$ & F $gdMf & F , xHJX (#$gdMf!$ & F )  xHX (#$a$gdMf Z#n#p#r#|#~#####%$8$K$h$i$j$$$$$$˴󪦟zobWzoJz=ha6:CJOJQJha56CJOJQJha5CJOJQJha5:CJOJQJha:CJOJQJha5:CJOJQJha5:CJOJQJha5CJOJQJ ha5CJhahMfCJOJQJ,jhMf5>*CJOJQJUmHnHu!jhMf5>*CJOJQJU-j=hhMf5>*CJOJQJUhMf5>*CJOJQJ'$8$9$:$_$h$i$j$t$$$\% )  xHX (#$$Ifl ($ )  xHX (#$$Ifa$l ($ )  xHX (#$$Ifa$l *$ )  xHX (#$2$Ifa$l  $$$$%Rkd$$Ifl4,rrl$```8$4 la*$ )  xHX (#$2$Ifa$l $$%% % %&h h hhhhhhhh.h0h2hh@hXhZhnhphϼںϘmڥcUcD!jhaCJOJQJUjhaCJOJQJUhaCJOJQJ$jha5CJOJQJUha5CJOJQJha5:CJOJQJha5:CJOJQJ)jha5CJOJQJUmHnHuU$jha5CJOJQJUha5CJOJQJjha5CJOJQJU ha5CJha56:CJOJQJ      FORMTEXT       Eligibility  FORMTEXT       MinutesFrequency (times per week/ month/ Year)WK/ Month/ YearStart Date1. Speech FORMTEXT       FORMTEXT    FORMDROPDOWN  FORMTEXT      Included in Bundled Hearing LCI Tuition Daily rate FORMTEXT       FORMTEXT  =f4*g4 0$0.002. Transportation LCI home to School FORMTEXT       FORMTEXT    FORMDROPDOWN  FORMTEXT      Included in Bundled Hearing LCI Tuition Daily rate FORMTEXT       FORMTEXT  0 $0.003. Temporary Support Assistant FORMTEXT       FORMTEXT    FORMDROPDOWN  FORMTEXT      Included in Bundled Hearing LCI Tuition Daily rate FORMTEXT       FORMTEXT  0 $0.004. Counseling FORMTEXT       FORMTEXT    FORMDROPDOWN  FORMTEXT      Included in Bundled Hearing LCI Tuition Daily rate FORMTEXT       FORMTEXT  0 $0.005. Behavior Plan Development FORMTEXT       FORMTEXT    FORMDROPDOWN  FORMTEXT      Included in Bundled Hearing LCI Tuition Daily rate FORMTEXT       FORMTEXT  0 $0.006. Behavior Plan Management FORMTEXT       FORMTEXT    FORMDROPDOWN  FORMTEXT      Included in Bundled Hearing LCI Tuition Daily rate FORMTEXT       FORMTEXT  =f9*g9 0$0.007.  FORMTEXT       FORMTEXT       FORMTEXT    FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT  =f10*g10 0$0.008.  FORMTEXT        FORMTEXT       FORMTEXT    FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT  =f11*g11 0$0.00*Maximum DIS and Related Services Cost Estimate(C)Above Estimated Totals  FORMTEXT  =h4+h5+h6+h7+h8+h9+h10+h11 $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  =d12+d13 $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  =c14/c15 !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. North Valley Schools, Santa RosaLocal Educational Agency  FORMTEXT      ________________________________________________________________________(Authorized Signature) (Date)(Authorized Signature) (Date)3164 Condo Court(Name)  FORMTEXT      Santa Rosa, CA 95403 FORMTEXT      (707) 523-2334 phone FORMTEXT      (707) 523-0133 fax(Mailing Address) FORMTEXT       Phone  FORMTEXT       Fax     PAGE 2 10/11 2010/11 North Valley Hearing 3632 LCI ISA Page  PAGE 1 of  NUMPAGES 2 %hhhhh]2*$ )  xHX (#$2$Ifa$l % )  xHX (#$$Ifl ($ )  xHX (#$$Ifa$l *$ )  xHX (#$2$Ifa$l ' )  xHX (#$2$Ifl hh@hXhh}UUU' )  xHX (#$2$Ifl kdR$$Ifl4rrl$   8$4 laphrh|h~hhhhhhhiiii i6i8iLiNiPiZi\i^iƹƟƔƍqdPq9qd,jha5:CJOJQJUmHnHu'jha5:CJOJQJUha5:CJOJQJ!jha5:CJOJQJUha5CJOJQJ ha5CJha5CJOJQJha5:CJOJQJha6:CJOJQJha5:CJOJQJha5:CJOJQJhaCJOJQJ&jhaCJOJQJUmHnHujhaCJOJQJUhhhhhhiiX*$ )  xHX (#$2$Ifa$l ' )  xHX (#$2$Ifl *$ )  xHX (#$2$Ifa$l ($ )  xHX (#$$Ifa$l iiii*$ )  xHX (#$2$Ifa$l % )  xHX (#$$Ifl ($ )  xHX (#$$Ifa$l i i6iD% ) h xHX 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