Service Plan for Students with Disabilities
Voluntarily Enrolled by Their Parents in Private Schools
PS-2
ROCK HILL SCHOOL DISTRICT – YORK 3
SCHOOL YEAR _______
Name:
DOB
Sex:
Grade:
Date of Service Plan Meeting:
Service Plan Initiation Date:
Anticipated Annual Review:
Primary Disability:
Other Disabilities:
Service Plan Ending Date:
Reevaluation due date:
Present Levels of Performance
Present Level(s) of Performance specific to the area(s) that will be addressed in this Service Plan.
Area(s) of Assessment
Method of Assessment
Date
Findings
Annual Goal:
Short term objectives
Criteria for Mastery
Evaluation Method
Results
Criteria for Mastery
Evaluation Method
Results
Annual Goal:
Short term objectives
Description of instructional accommodations and modifications necessary to help the student progress:
Progress toward annual goals will be reported to the parents at each report card period by indicating results of short
term objectives or sending a Progress Report.
Revised 10-19-09
1
Related Services
Is transportation necessary to implement this Service Plan?
Yes
No
If yes, how will transportation be provided _____________________________________________________
Modifications to Regular Education
Extent of this student's participation in academic, nonacademic, and extracurricular activities in the regular
educational environment: _____/hours/week.
Supplementary Aids and Services will be provided to, or on behalf of, the student, to support this student's
participation in academic, nonacademic, and extracurricular activities in the regular educational environment, as
follows:
Service
Location
Description
Supplementary Aids
Location
Anticipated frequency
Will this student participate in statewide testing through the Rock Hill School District?
Yes
If yes, please attach accommodations/modifications (use the current section from EXCENT).
No
COMMITTEE MEMBERS
The following individuals have attended the SERVICE PLAN/LRE meeting and participated as equal members in the
development of this SERVICE PLAN. Consideration has been given to the following, as appropriate to the individual
student:
____ Notice of Rights under the Individuals with Disabilities Education Act (IDEA) that will transfer to the student at the
age of 18 have been given to the student who will become 17 during the effective dates of the SERVICE PLAN.
N/A
By signature below, we agree with the education and related services to be provided to this student as delineated in
the SERVICE PLAN. Our LRE recommendations and this student's placement are based on the completed SERVICE
PLAN and the regulations set forth by the Individuals with Disabilities Education Act (IDEA).
Signature/Position
Signature/Position
Signature/Position
I have been given an opportunity to attend and participate as an equal member in the SERVICE PLAN meeting. I have
read the SERVICE PLAN documents, or had them read to me, and understand the contents and the SERVICE PLAN
process; and
___ I agree with the educational services to be provided to my child as delineated in this SERVICE PLAN, or
___ I choose not to accept the educational services delineated in this SERVICE PLAN.
___I understand that if I plan to enroll my child in the Rock Hill School District, an IEP meeting will be convened to
discuss the provision of a free appropriate education in that setting.
Signature of Parent/Legal Guardian/Surrogate Parent
Revised 10-19-09
Student (if appropriate)
Date
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