Individual Service Agreement Under the Sonoma County Special Education

INDIVIDUAL SERVICE AGREEMENT UNDER THE SONOMA COUNTY SPECIAL EDUCATION 2016/2017 MASTER CONTRACT FOR NONPUBLIC, NONSECTARIAN SCHOOL/AGENCY SERVICES - Exhibit B ISA Nonpublic School/Agency: Local Education Agency: Pupil’s Name: Sex: M F Birthdate: Grade: Primary Disability: Residential Setting: HOME FOSTER LCI Parent/Guardian’s Name: Pupil’s Address: LCI/FFH Lic. Number:

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 pupil’s Individualized Education Program (IEP) in accordance with this Individual Service Agreement (ISA) and the Contract. Invoices shall be submitted based on actual service provided and attendance standards in the Contract. A. Daily Tuition Estimate: Pupil shall be enrolled at commencing on , and ending on , unless earlier terminated by notice from LEA upon pupil’s change of residence, change of placement or termination of the Master Contract. Number of Rate Per Day Total Regular Regular School Year 0=b1*d1 Number of Rate Per Day Total ESY ESY Days Basic 0=b2*d2 Partial Day Partial Day Student - Student – Total Regular Number of Rate Per Number of minutes per School Year Regular Minute 0=(d3*f3)*b3 day Basic School Year Education Days Costs Partial Day Partial Day Student - Number of Student - Rate Per Total ESY minutes per 0=(f4*d4)*b4 Number of Minute day Basic ESY Days Education Costs Total Basic Total 0=b1+b2 Education Instructio Costs $0.00=f1+f2+h3+h4 nal Days +b3+b4 -Adjusted Annually B. Nonpublic Agency Services and/or Designated Instruction & Related Services Estimate:

STIMATED OTAL DURATION FREQUENCY E T = WEEK ESTIMATED SERVICE MASTER CONTRACT - MINUTES Times per HOURS PER Cost per hour x SERVICE MONTH ISA SERVICE START DATE RATE PER Week or or YEAR estimated OR YEAR SESSIONS SESSION Month service hours or sessions 1. $0.00 $0.00=(d9* g9)/60*c9+ (i9*c9) 2. $0.00 $0.00=(d10 *g10)/60*c1 0+ (i10*c10) 3. $0.00 $0.00=(d11 *g11)/60*c1 1+ (i11*c11) 4. $0.00 $0.00=(d12 *g12)/60*c1 2+ (i12*c12) 5. $0.00 $0.00=(d13 *g13)/60*c1 3+ (i13*c13)

Exhibit b ISA 6. $0.00 $0.00=(d14 *g14)/60*c1 4+ (i14*c14) 7. $0.00 $0.00=(d15 *g15)/60*c1 5+ (i15*c15) 8. $0.00 $0.00=(d16 *g16)/60*c1 6+ (i16*c16) 9. $0.00 $0.00=(d17 *g17)/60*c1 7+ (i17*c17) 10. $0.00 $0.00=(d18 *g18)/60*c1 8+ (i18*c18) 11. $0.00 $0.00=(d19 *g19)/60*c1 9+ (i19*c19) 12. $0.00 $0.00=(d20 *g20)/60*c2 0+ (i20*c20) 13. $0.00 $0.00=(d21 *g21)/60*c2 1+ (i21*c21) 14. $0.00 $0.00=(d22 *g22)/60*c2 2+ (i22*c22) Maximum NPA Services and/or Designated Instruction & Related Services Cost - Estimate $0.00=j22+j 21+j20+j1 9+j18+j17 +j16+j15+j1 4+j13+j12+ j11+j10+j9 Estimate Per DIEM =d24/b5 Maximum Total Basic Education & DIS/Related Services Cost - Estimate $0.00=b23+d 5

C. Individual Pupil Specifications:

The parties hereto agree to comply with the terms of the Master Contract & hereby execute this ISA by and through their duly authorized agents or representatives. Nonpublic Agency: Local Educational Agency:

(Authorized Signature) (Date) (Authorized Signature) (Date)

2 Phone Fax Phone Fax

Exhibit b ISA