Special Education

Application for Approval of July/August Special Class Programs (Program Code 9000 and 9010)

Form J/A 2013-9000/9010 - Application for Approval of July/August Special Class Programs (Program Code 9000 and 9010) - Word word document (116 KB)

Check One Only:  __ Full-day (9000)   or   __ Half-day (9010) Special Class Program

Please complete this application form for NEW extended school year full-day (9000) and/or half-day (9010) Special Class proposed program(s) for which you are seeking funding approval.  The System to Track and Account for Children (STAC) and Special Aids Unit will use the information on this form as the basis for the review of student STAC forms.  Applicants must also complete the Assurances on pages 3-4.

General Information

1.Legal Name of School/Agency
2. Mailing Address of School or Agency Administrative Office Street
City                                                     State                                      Zip
3. Address of Program Site(s), if different (attach addresses of other sites, if applicable) Street
City                                                     State                                      Zip
4. County and School District where Administrative Office is Headquartered County
School District
5.Contact Person/Title 6.School's/Agency's 12-digit SED Code (required)
7.Telephone/Email Address
Area Code            Number                  Ext.           
Email Address:                                                    
8. Fax Number
Area Code            Number     

9.   Check each disability of the students attending this program:

  Autism   Intellectual Disability   Speech or Language Impairment
  Deafness   Learning Disability   Traumatic Brain Injury
  Deaf-Blindness   Multiple Disabilities   Visual Impairment
(including Blindness)
  Emotional Disturbance   Orthopedic Impairment
  Hearing Impairment   Other Health Impairment

10. Age (range) of student(s):            to           [8 NYCRR §200.6(h)(5)]

11. Number of hours of daily instruction excluding the lunch period and transportation:                                                                                                 

12. What staffing ratios will be used in this program?  Please check the appropriate box(es) and complete the second row of the chart accordingly.

Staffing Ratio 15:1 12:1* 12:1+1 6:1+1 8:1+1 12:1+(3:1) Other
Number of Classes at Each Staffing Ratio              

13. Please complete the information below:

  • How many New York State students are expected to be served in this program during July/August?     
  • How many will be full-time day students?         
  • How many will be less than full-time day students?        

14.  Check the related services that will be provided:

 Audiology Services  Psychological Services  Other:
 Counseling  School Social Work  Other:
 Occupational Therapy  Speech/Language Therapy  Other:
 Physical Therapy  Vision Services  Other:

15. Dates of this program:  Beginning 7/     /13 - Ending 8/     /13

16. Number of days the program will operate          

*State-operated or State-supported schools only


Assurances for July/August Special Class Programs

Instructions:  Read and initial each one of the assurances listed below and sign and date the Certification Statement.  Attach one copy with each application the school/agency is submitting for approval.

Special class programs will be provided in accordance with Article 89 of the Education Law and Part 200 of the Regulations of the Commissioner of Education, including but not limited to:

  • Related services shall be provided by individuals with appropriate certification or license in each area of related service. [8 NYCRR §200.6(b)(3)]
  • Special education instruction shall be provided by individuals appropriately certified or licensed pursuant to Part 80 of the Regulations of the Commissioner of Education. [8 NYCRR §200.6(b)(4)]
  • Students with disabilities placed together for purposes of special education will be grouped based on similarity of need. [8 NYCRR §200.6(a)(3)]
  • Special class programs will operate for at least 30 school days during the months of July and August and will be funded for a maximum of 30 days of service.  For the July 2013 to August 2013 extended school year, the calendar must include at least 30 days during July and August.  In observance of Independence Day as a legal holiday, July 4th may constitute a day of service for a July-August program, provided that day is included in your program calendar dates. [8 NYCRR §200.1(eee)]
  • The length of the school day for a full-day special class program shall be not less than five hours of instruction for students whose chronological ages are equivalent to those of students in grades K through 6, and not less than 5 ½ hours of instruction for students whose chronological ages are equivalent to those of students in grades 7 through 12.  The length of the school day for a half-day special class program shall be not less than 2 ½ hours of instruction for students whose chronological ages are equivalent to those of students in grades K through 6, and not less than three hours of instruction for students whose chronological ages are equivalent to those of students in grades 7 through 12.  The school day shall include instructional activities and related services, but does not include lunch and transportation. [8 NYCRR §200.7(b)(4) and §200.1(q) and (v)]
  • Special education and related services will be provided consistent with each student’s individualized education program (IEP). [8 NYCRR §200.6(a)(2)]
  • Parents of students with disabilities shall not be asked to make any payments in lieu of, in advance of or in addition to, State, school district or county payments for allowable costs for students placed according to New York State procedures. [8 NYCRR §200.7(b)(1)]
  • Appropriate accounting documentation will be maintained and necessary financial reports will be provided to the New York State Education Department. (NYSED) [8 NYCRR §200.9(d) and (e)].
  • The confidentiality of personally identifiable data, information or records pertaining to a student with a disability will be maintained, and parental access to such records will be afforded in accordance with §§200.5(d)(6) and (e)(2) of the Regulations of the Commissioner of Education.
  • Special education programs and services will be provided in nonsectarian, neutral settings.
  • The approved program will conform to all applicable fire and safety regulations of the State and municipality in which the program/service(s) is located.
  • The approved program will comply with NYSED’s policies and procedures pertaining to the administration of medications to students (for more information, please go to the following web site:  http://www.schoolhealthservicesny.com/uploads/AdminMed.pdfexternal link).
  • The approved program has policies and procedures for responding to medical emergencies.
  • The discipline of students with disabilities attending the approved program will be consistent with Part 201 of the Regulations of the Commissioner of Education.
  • Approved  programs will comply with section 19.5 of the Rules of the Board of Regents and section 200.22 of the Regulations of the Commissioner of Education relating to program standards for behavioral interventions, including the prohibition on the use of aversive interventions to reduce or eliminate maladaptive behaviors. [8 NYCRR §200.7(b)(8)]

Certification Statement

I, the undersigned, have read and attest that the initialed assurances as required in this application are accurate and will be fulfilled with regard to the special class programs operated by this school/agency.

Name                                                      Signature                             

Title                                                                              Date              

Last Updated: March 17, 2014