Noneducational Community-Based Support Services
Application for Funding
Education Service Center Region 10
Fiscal Year 2010-2011 Authority for Data Collection: TEC ?29.013 Planned Use of Data: To determine the cost of noneducational community-based support services for students with disabilities and ensure that this request for service is in accordance with state laws and rules. Instruction: Complete each item. For further information, contact your Education Service Center. Enter an “X” in the box to indicate whether the request for funds is new (application submitted first time for this student), continuing (application submitted for this student to continue services), or amendment/cost revision (to revise activity or cost of an approved application).
New Continuing Amendment/Cost Revision
Parent(s) or Guardian(s) is in agreement with this application.
List student Disability/Disabilities, if any: Sex: M F Age (as of 9/01 of current fiscal year): Ethnicity: ESC Stamp-in Date Primary Language:
Student’s District of Residence or Charter School: County-District No.:
Home Campus: Campus Attending:
Dates of Services: Beginning: Ending:
Name of Person Completing Application: Telephone:
Parent/Guardian Name: Telephone:
Mailing Address of Person Completing Application: Typed Name and Title of Special Education Contact Person for LEA Telephone
Typed Name of Mental Retardation Authority (MRA) or Mental Health Authority Check One CRCG/MRA/MHA Telephone (MHA), or Community Resource Coordination Group (CRCG) MRA Contact Person MHA CRCG If the student’s district of residence or charter school is a member of a shared services arrangement, the fiscal agent superintendent’s signature assures that the sending member accepts and agrees with the following assurances. The responsible LEA assures its local Education Service Center (ESC) of the following: The single member district, charter school, or fiscal agent district (if student resides in a member district of a special education shared services arrangement) applying for the noneducational community-based support services will: 1. Ensure that an interagency group of people knowledgeable about the student and the parents have agreed upon the services to be provided, and 2. Develop a contract with the provider of noneducational community-based support services. CERTIFICATION We certify that the information in this document is true and correct and that these statements of assurance are accepted and we certify that the provision of services does not supersede or limit the responsibility of other agencies to provide or pay for costs of noneducational community-based support services. We certify that parents, CRCG, MRA/MHA staff, and local education agency (LEA) staff were involved in the development of this application. We certify that any ensuing program and activity will be conducted in accordance with federal and state laws and regulations. It is understood by the applicants that this application constitutes an offer and will form a binding agreement. To be signed by the authorized representative of the MRA, MHA, or CRCG, i.e. the superintendent of a state school, the director of a state center, the executive director of a community center. The signature of the CRCG chairperson serves only as verification that staff were consulted regarding services for the student named in this application.
Typed Name and Title of Authorized Representative of Date Telephone Signature MRA, MHA, or CRCG Chairperson To be signed by the superintendent or designee of a single member district or the fiscal agent district for the shared services agreement. If anyone other than the superintendent signs this application, the appropriate authorization must be attached. Typed Name and Title of Authorized Representative for Date Telephone Signature School District/Fiscal Agent
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NOTE: Services provided under this section shall not be used for a student with disabilities who is in need of residential placement for noneducational reasons. These funds may not be used if the services described below could be provided with education funds. (Families with a child with Autism can only be provided with respite care or attendance care. In-home training of viable alternatives and parent training that support the student’s individualized education program (IEP) must be paid with educational funds as required by TAC ?89.1055(e)). The following questions must be completed by district staff to provide adequate information for ESC staff to ensure that necessary criteria are met before this application is approved. Be specific when providing answers.
1. Current Status. This student is:
At risk for private residential placement for educational purposes.
Returning from private residential placement.
2. Briefly describe your impressions of the student.
3. Briefly describe the student’s strengths.
4. Describe the student’s behavior(s) that have resulted in the need for noneducational services. List specific
behaviors observed at home and at school, including frequency (how often the behavior occurs) and duration
(the period of time in which each behavior occurs; i.e. daily, weekly, monthly, yearly).
5. List academic and behavior intervention(s) implemented by the district regarding behaviors described in
Question 4 and include the instructional setting and teacher/student ratio.
6. For continuing applications, describe the previous use of and benefit from noneducational funds.
7. Describe MRA/MHA or any other agency involvement that has focused on maintaining the student in the
home and in the local school program.
8. List previous out-of-home placements and provide the reason and duration for each.
9. Describe anticipated future funding needs and include other sources of funds for services.
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10. Briefly describe pertinent academic and behavioral information for each year. This information must be
based on a student’s individualized educational program (IEP), report card, or any other progress reports. Fiscal Year Name of Facility or LEA Academic Information Behavioral Information