FY2012 GRANT FOR RESIDENTIAL AND REINTEGRATION SERVICES

Georgia Department of Education

Division for Special Education Services and Supports

SYSTEM:

System Contact:

Phone:

Email:
[ ] Initial

[ ] Continuation	[ ] Parent Custody

[ ] Ward of the State
Student's Name:	Date of Birth:
The Student's Primary Disability:

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

Mother's/Guardian’s/Surrogate’s Full Name:
Home Address:
(Street) (City/State) (Zip) ( Phone)
Private Residential School Name: Phone:

For an out of state school: Submit documentation that school is on the approved list for the state in which it resides.
Address:

Contact Person:
Provide the specific cost breakdown for services provided by the private residential school. Total cost of over $30,000 should be used as the minimum to be considered in the application. Invoices required.
Special Education Services	$ day/month
Related Services	$ day/month
Room and Board	$ day/month
TOTAL COST OF RESIDENTIAL PLACEMENT	$ day/month
$__________/Month X ___Months OR $_____/Day X ____ Days

Need actual months or days served for educational program only

$
List source and amount of third-party funds (ex. Health insurance, Medicaid) to be utilized or indicate NONE if no third party funds used):

Source: Amount: $
BEGINNING DATE: ENDING DATE:

NOTE: These dates are necessary for calculating total cost of services.

INITIAL APPLICATION Complete the following information for initial residential placement. Describe the programs, intervention, and length of time in which the student participated. (Refer to Instructions for descriptions of categories below)

PROGRAM SERVICES	INTERVENTION	LENGTH OF PLACEMENT (S)
Public School Programs:
Regional Programs/ Shared Services:
State-supported Programs:
CONTINUATION APPLICATION Complete the following information for continuing residential placement. Describe the programs and length of time in which the student previously participated. Report the date of the student’s initial placement into a residential program.

In State:

Out of State:

Date of initial residential placement:

The student cannot be appropriately served in a:

[ ] school system [ ] regional program, or [ ] state-supported program.

All three must be checked before a grant for a private residential program will be considered.

If the residential program is out of state, describe your efforts to find an in state program.

Describe the specific needs of the student for placement in a private residential program. This must be documented in the placement minutes and/or the IEP.

List the date(s) the system visited the residential program:

EXTENDED SCHOOL YEAR

Complete this section if the IEP dates for services exceed nine school months or 180 days.

1. Describe the need for extended year funding beyond 180 days. Attach a copy of the IEP placement minutes developed to meet the student’s extended year needs.
2. Provide an explanation of how the requested days will meet the identified needs in the private residential school.

REINTEGRATION PLAN

Required for ALL students

Plan for transitioning the student into a less restrictive environment.

Date Developed;_______________________ Review Date(s): ________________________________________

1. Describe the plan for moving the student toward a less restrictive, in-community or day program. (Include the involvement of other public and/or private agencies in this transition.)

2. Describe the specific timeline for this plan.

3. Describe the plan for assisting the student’s parents in the development of the necessary skills for this transition.

ASSURANCE STATEMENT

GRANT FOR RESIDENTIAL AND REINTEGRATION SERVICES

IF THIS GRANT APPLICATION IS NOT APPROVED, I UNDERSTAND THAT THE SYSTEM IS RESPONSIBLE FOR ALL THE COSTS FOR SERVICES STATED IN THE STUDENT’S IEP.

_______________________________ _____________________

Signature of Superintendent Date

_______________________________

School System

Georgia Department of Education

Dr. John D. Barge, State School Superintendent

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GRANT APPLICATION

GADOE

2011-11-16

Sarah Kemph

Georgia Department of Education