SYSTEM:

Date:
System Contact:

Phone #:

Email address:
[ ] Initial Grant

[ ] Continuation Grant	Ward of the State Y( ) N( )
Student's Name:	Date of Birth:
Student's Primary Disability:	Secondary Disability:
Father's/Guardian’s/Surrogate’s Full Name:

Mother's/Guardian’s/Surrogate’s Full Name:

Home Address:

Home Address:

(Street) (City)

(Street) (City)

(Zip) ( Phone)	(Zip) ( Phone)
PROVIDE THE SPECIFIC and/or PROPRATED COST BREAKDOWN TO MEET THE UNIQUE NEEDS OF THIS HIGH COST CHILD. Complete the Cost Worksheet Summary included in the grant application to calculate the amounts for the line item cost totals listed below. (Total cost of over $27,000 should be used as the minimum to be considered in the application.
1 Special Education Services	$
2 Related Services	$
3 Other costs	$
4 TOTAL COST of Child	$
5 Minus 3X annual cost	- $ 27,000
6 Minus third- party funds

(ex. Health insurance, Medicaid) – if none

indicate NA	- $
TOTAL Allowable GHCF

(Line 4 minus line 5 and 6)

$

Invoices for any contractual services and any IEP’s that document the services and expenses must be included with the grant application. The costs occur in FY2012 (July 1, 2011 to June 30, 2012) and funds must be spent by June 30, 2012.

COST WORKSHEET SUMMARY Use this worksheet to itemize the totals recorded on page 1 of the GHCF application. All services calculated for cost must be included in the student’s IEP.
Category of Expenditure	Description of Service Provided	Amount
1) Special Ed Services
(Ex- Teacher Costs, Materials/
Supplies specific to the child)
Total	Transfer this amount to Line 1 – Special Ed Services – Page 1	$
2) Related Services
(Ex- Transportation, OT, PT
Nursing Services)
Total	Transfer this amount to Line 2- Related Services – Page 1	$
3) Other Costs
(Ex-Consultations, Training
Costs, Independent Evaluations)
Total	Transfer this amount to Line 3 – Other Costs – Page 1	$
6) Third party funds
(Ex- Health Ins., Medicaid)
Total	Transfer this amount to Line 6- Third Party Costs - Page 1	$

INITIAL APPLICATION Complete the following information to describe the prior programs, interventions and duration of interventions in which the student has participated.

DESCRIBE PRIOR SPECIAL EDUCATION SERVICES	INTERVENTION (S)	DURATION OF INTERVENTION

Describe the unique features of the child determined to be “high need.”

(Include developmental, cognitive, social emotional and medical factors)

Summarize the individualized education program developed for the child.

(Description should include all evaluations/consultations/services provided through the IEP and funded by the GHCF)

Provide a copy of the student’s current Individual Education Program (IEP) outlining the services for the high cost child.

Beginning Date: Ending Date:

Describe the timelines established to monitor progress of the child.

(Include dates and describe the data used to monitor progress)

Will the plan result in a reduction of services in the future?

If yes, describe the anticipated outcomes for the child as a result of this intensive intervention.

If no, describe the chronic nature of the child’s disability.

Describe any specialized training to implement the plan for the high cost child?

( Include training for staff, as well as, parents or caregivers)

Georgia Department of Education

Dr. John D. Barge, State School Superintendent

FY2012 GRANT FOR HIGH COST FUND

Division for Special Education Services and Supports

Return the Grant Application and Supporting Documentation to:

Michael Blake

1870 Twin Towers East

205 Jesse Hill Drive.SE

Atlanta, GA 30334

FY2010_GRANT_FOR_HIGH_COST_FUND

GaDOE

2011-11-16

Sarah Kemph

Georgia Department of Education