JA-Application.htm

Form J/A 03: APPLICATION for APPROVAL of JULY/AUGUST PROGRAM/SERVICE(S)

Please complete every question in this application form for each extended school year program/service(s) for which you are seeking funding approval. The STAC and Special Aids Unit will use the information on this form as the basis for the review of student STAC forms.

1.	Name of school:	________________________________________________________
	SED School Code:	________________________________________________________
2.	Name of the specific extended school year program/service(s) for which you are seeking approval (CHECK ONLY ONE): ____________________________________________________________
	[ ] Full (9000) or Half-Day (9010) Instruction in Special Class Program
	[ ] Related Services Only (9015)
	[ ] Specialized Instruction (9029)
	[ ] Specialized Instruction with Related Services (9025)
	[ ] Home/Hospital Instruction (9022)
3.	Address:	___________________________________________________________ (Street and/or Post Office Box)
		___________________________________________________________ (City) (State) (Zip)
		___________________________________________________________ (County)
	Address if location of program/service(s) is different from the address above:
		__________________________________________________________ (Street and/or Post Office Box)
		__________________________________________________________ (City) (State) (Zip)
		__________________________________________________________ (County)
	Telephone:	_____________________________ Fax: _________________________
4.	E-mail address:	__________________________________________________________
5.	Contact Person:	__________________________________________________________
	Title:	__________________________________________________________
6.	Circle PRIMARY disability(ies) of students attending this program/service(s):
	Autistic	Deaf	Orthopedically Impaired
	Emotionally Disturbed	Hard of Hearing	Other Health-Impaired
	Learning Disabled	Speech-Impaired	Multiply Disabled
	Mentally Retarded	Visually Impaired	Deaf/Blind
			Traumatic Brain Injury
7.	Age (range) of student(s): _______ to _______
8.	Dates of this program/service(s): Beginning 7/_____/03 Ending 8/____/03
9.	Number of hours of daily instruction excluding the lunch period: ________________
10.	What staffing ratios will be used in this program/service(s)?

Staffing Ratio 15:1 12:1 12:1+1 8:1+1 6:1+1 12:1+4 Other options…

List # of Classes at Staffing Ratio

11.
How many New York State students are expected to be served in this program during July/August? ______

How many will be full-time day students? ___________

How many will be less than full-time day students? _______

How many will be residential? ________

How many students will have 12-month IEPs? ___________

12. What related services will be provided? ____________________________________________

__________________________________________________________________________

13. Will this special education program/service(s) be provided in a setting with nondisabled peers? Yes______ No_____ If yes, please specify setting. __________________________________________________________________________

14. Draw a box ( [ ] ) around all the dates on the calendar below to show the days of program/service(s) instruction .

JULY 2003 AUGUST 2003

M T W Th F M T W Th F

. 1 2 3 4 . . . . 1

7 8 9 10 11 4 5 6 7 8

14 15 16 17 18 11 12 13 14 15

21 22 23 24 25 18 19 20 21 22

28 29 30 31 25 26 27 28 29

15. Please ATTACH DOCUMENTATION of the procedures used to handle:

serious health emergencies (indicate distance to nearest hospital).

first aid.

dispensing medication to students.

procedures and in-service training provided to staff to insure that any unusual medical and health needs of these severely disabled students will be met in an appropriate manner.

16. All programs/services must indicate the proposed start and finish time for each component of the instructional day. If you plan to operate the program/service(s) in more than one site, duplicate the table below and complete for each site.

Site location: ____________________________________________ (Street) (City)

morning session
start/finish) lunch time
(start/finish) afternoon session (start/finish)

Monday ____________________ __________________ _____________________

Tuesday ____________________ __________________ _____________________

Wednesday ____________________ __________________ _____________________

Thursday ____________________ __________________ _____________________

Friday ____________________ __________________ _____________________

17. ASSURANCES

This special education program and services will be provided in accordance with Section 4408 of the Education Law and Part 200 of the Regulations of the Commissioner of Education and will include but not be limited to:

The special education program and services and staff will meet all certification and education standards pursuant to Part 200 and Part 80 of the Regulations of the Commissioner of Education.

The special education program and/or services will operate for at least 30 days during the months of July and August only.

All instructional and related services will be provided consistent with each student’s Individualized Education Program (IEP).

Publicly funded school-age students will not be admitted into the special education program and/or services without an IEP from the Committee on Special Education (CSE).

Parents of students attending programs and services governed by this section will not be asked to make any payments for allowable costs for students placed according to NYS procedures.

Programs will maintain appropriate accounting documentation and provide necessary financial reports when requested.

The confidentiality of personally identifiable data, information or records pertaining to a student with a disability will be maintained in accordance with the provisions of 34 CFR Part 300, 34 CFR Part 99 and Section 200.5 (e) (2) of the Regulations of the Commissioner.

All programs and services will be provided in non sectarian, neutral settings.

To the maximum extent appropriate, students with disabilities will be educated with students who are nondisabled (34 CFR 300.550).

Programs will comply with all applicable fire and safety regulations of the State and municipality in which the program/service(s) is located.

I, the undersigned, attest that the assurances provided are accurate regarding this program/service(s).

Name___________________________ Signature________________________________

Title _________________________________________ Date _____/____/ 2003

Staffing Ratio	15:1	12:1	12:1+1	8:1+1	6:1+1	12:1+4	Other options…
List # of Classes at Staffing Ratio

11.	How many New York State students are expected to be served in this program during July/August? ______
	How many will be full-time day students? ___________
	How many will be less than full-time day students? _______
	How many will be residential? ________
	How many students will have 12-month IEPs? ___________
12.	What related services will be provided? ____________________________________________
	__________________________________________________________________________
13.	Will this special education program/service(s) be provided in a setting with nondisabled peers? Yes______ No_____ If yes, please specify setting. __________________________________________________________________________
14.	Draw a box ( [ ] ) around all the dates on the calendar below to show the days of program/service(s) instruction .
	JULY 2003					AUGUST 2003
	M	T	W	Th	F	M	T	W	Th	F
	.	1	2	3	4	.	.	.	.	1
	7	8	9	10	11	4	5	6	7	8
	14	15	16	17	18	11	12	13	14	15
	21	22	23	24	25	18	19	20	21	22
	28	29	30	31		25	26	27	28	29

15.	Please ATTACH DOCUMENTATION of the procedures used to handle:
	serious health emergencies (indicate distance to nearest hospital).
	first aid.
	dispensing medication to students.
	procedures and in-service training provided to staff to insure that any unusual medical and health needs of these severely disabled students will be met in an appropriate manner.
16.	All programs/services must indicate the proposed start and finish time for each component of the instructional day. If you plan to operate the program/service(s) in more than one site, duplicate the table below and complete for each site.
	Site location: ____________________________________________ (Street) (City)
		morning session start/finish)	lunch time (start/finish)	afternoon session (start/finish)
	Monday	____________________	__________________	_____________________
	Tuesday	____________________	__________________	_____________________
	Wednesday	____________________	__________________	_____________________
	Thursday	____________________	__________________	_____________________
	Friday	____________________	__________________	_____________________

17.	ASSURANCES
	This special education program and services will be provided in accordance with Section 4408 of the Education Law and Part 200 of the Regulations of the Commissioner of Education and will include but not be limited to:
	The special education program and services and staff will meet all certification and education standards pursuant to Part 200 and Part 80 of the Regulations of the Commissioner of Education.
	The special education program and/or services will operate for at least 30 days during the months of July and August only.
	All instructional and related services will be provided consistent with each student’s Individualized Education Program (IEP).
	Publicly funded school-age students will not be admitted into the special education program and/or services without an IEP from the Committee on Special Education (CSE).
	Parents of students attending programs and services governed by this section will not be asked to make any payments for allowable costs for students placed according to NYS procedures.
	Programs will maintain appropriate accounting documentation and provide necessary financial reports when requested.
	The confidentiality of personally identifiable data, information or records pertaining to a student with a disability will be maintained in accordance with the provisions of 34 CFR Part 300, 34 CFR Part 99 and Section 200.5 (e) (2) of the Regulations of the Commissioner.
	All programs and services will be provided in non sectarian, neutral settings.
	To the maximum extent appropriate, students with disabilities will be educated with students who are nondisabled (34 CFR 300.550).
	Programs will comply with all applicable fire and safety regulations of the State and municipality in which the program/service(s) is located.
I, the undersigned, attest that the assurances provided are accurate regarding this program/service(s).
Name___________________________ Signature________________________________
Title _________________________________________ Date _____/____/ 2003