FONTANA UNIFIED SCHOOL DISTRICT
State and Federal Programs Office
Supplemental Educational Services (SES)
Student Learning Plan (SLP) 2013-14
PROVIDER: Choose an item.
Date of Consultation Meeting:
PART I: STUDENT INFORMATION
Last Name: Click here to enter text.First Name: Click here to enter text.
School: Choose an item. School ID: Click here to enter text.
Gender: Choose an item.
Grade: Choose an item.
Primary or Homeroom Teacher’s Name: Click here to enter text.
Ethnicity: Choose an item.
Student Primary Language: Choose an item.
Parent/Guardian Name: Click here to enter text.
Home Number: Click here to enter text.
PART II: MODIFICATION(S) FOR INSTRUCTION
Services this student receives (check all that apply):
☐ English Language Learner
☐ Special Ed/504 Plan
IEP Modifications for Instruction:
☐ Visual Examples
☐ Modify Length of Assessment
☐ Divide Task into Parts
☐ Mark in Book
☐ Oral Tests (read aloud)
☐ Use of Dual Language Dictionary
☐ Concrete Instruction (hands on)
☐ Other: Click here to enter text.
IEP Goals in Mathematics
List Mathematics IEP goals if applicable (and any modifications for assessments):
Click here to enter text.
IEP Goals in English Language Arts
List ELA IEP goals if applicable (and any modifications for assessments):
Click here to enter text.
PART III: ASSESSMENT DIAGNOSTIC INFORMATION
Content Area Focus: ☐ English Language Arts
☐ Mathematics
Assessment Name: Click here to enter text.
Raw Score (# out of #): Click here to enter text.
Percent Correct: Click here to enter text.
PART IV: ACHIEVEMENT GOALS
Attach relevant academic data which may include: California Language Arts and Mathematics standards test results, report card,
samples of student work, etc. If this student is in Special Education, attach IEP Learning Goals.
Select an appropriate standard based on student need rather than a standard based on his/her grade level.
Original – District, Copies: Provider, Parent, School
Page 1 of 3
GOAL 1 - Choose an item.
Develop a specific achievement goal the student has not mastered and can significantly contribute to the student’s success
in English Language Arts and/or Mathematics. Goal should be a measureable SMART goal and aligned to the California State
Standards.
Click here to enter text.
GOAL 2 - Choose an item.
Develop a specific achievement goal the student has not mastered and can significantly contribute to the student’s success
in English Language Arts and/or Mathematics. Goal should be a measureable SMART goal and aligned to the California State
Standards.
Click here to enter text.
GOAL 3 - Choose an item.
Develop a specific achievement goal the student has not mastered and can significantly contribute to the student’s success
in English Language Arts and/or Mathematics. Goal should be a measureable SMART goal and aligned to the California State
Standards.
Click here to enter text.
How will progress toward achieving these goals be measured?
Click here to enter text.
What is the timeline for improving achievement? In the case of a student with disabilities, the timetable will be consistent
with the student’s Individual Education Program (IEP) pursuant to the individuals with Disabilities Education Act.
Services planned from Click here to enter a date. to Click here to enter a date..
How will parents and the student’s teacher be regularly informed of student progress?
☐ monthly
☐ bimonthly
☐ other Click here to enter text.
Procedure for notification: Click here to enter text.
PART V: SERVICES PROVIDED
Number of sessions covered by this agreement: Click here to enter text.
Number of hours: Click here to enter text.
Location of services: ☐ in-home ☐ school site ☐ center or provider facility ☐ other Click here to enter text.
Type of service: ☐ individual ☐ small group (2-5) ☐ large group (5-10) ☐ other Click here to enter text.
Attendance:
Students must attend supplemental services on a regular basis. Absences in excess of Click here to enter text. days will result in
termination of services. Supplementary service provider will notify district and parent that services have been terminated.
Termination of Services:
The parent, district representative, and supplemental services provider have a right to terminate services if the provider is unable to
meet stated goals and timelines. Parents will notify in writing their request to terminate the services of a supplemental provider.
Method of Payment:
Each supplementary service provider will submit monthly attendance records indicating service dates or dates of service for the student
and signed off by the student/parent. This form will identify the hourly rate per student. Each student will receive up to $ 936.75 for
the 2013-14 school year for supplemental services. Any request for additional funds are outside the responsibility of the district and
rests with the supplementary service provider and parent.
The agency/provider will submit a request for payment, along with a student attendance record, and fingerprint certification form (if
applicable) on a monthly basis.
Parent and supplementary service provider agrees to an hourly payment rate of $Click here to enter text.
Original – District, Copies: Provider, Parent, School
Page 2 of 3
Parent AGREES to release the following information regarding his/her student to the contracted agency/provider: Name, address,
phone number, academic information, and an IEP/504 Plan if applicable.
Parent Initials
The Supplemental Service Provider AGREES NOT TO DISCLOSE to the public the identity of this student without written consent of
the parent.
Provider/Agency Initials
I have reviewed the Student Learning Plan and agree to the statement of goals and developed timeline in this agreement. I have been
given the opportunity to participate in the development of this plan.
Parent/Guardian Signature
Date
Signature of Teacher/District Representative
Date
SES Provider/Agency Signature
Date
EVIDENCE OF REASONABLE ATTEMPTS FOR PARENTAL INPUT
As a provider, reasonable efforts must be made to contact the parents of the above-named student regarding SLP consultation and to
obtain the parent/guardian’s signature (three different attempts are deemed reasonable). However, if after these attempts, the provider
is unable to contact his/her parent/guardian to conduct an in-person meeting, or have consulted with the parent but have been unable
to secure their signature, the LEA and provider must develop an SLP for the student, even if the parent/guardian elects not to
participate in the consultation. All attempts must be logged in the chart below.
1st ATTEMPT
2nd ATTEMPT
(Insert a  in the appropriate box)
Date
Letter
Hm
Visit
Phone
3rd ATTEMPT
(Insert a  in the appropriate box)
Other
Date
Letter
Hm
Visit
Phone
(Insert a  in the appropriate box)
Other
Date
Letter
Hm
Visit
Phone
Other
Notes/Comments:
Original – District, Copies: Provider, Parent, School
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