Special Education

Application Checklist
Out-of-State Residential or Emergency Interim Placement
2012-13 School Year

For Office Use Only
Date Received: ___________
Application Complete

Application Checklist - Out-of-State Residential or Emergency Interim Placement - 2012-13 School Year

Application Checklist - Out-of-State Residential or Emergency Interim Placement - 2012-13 School Year - Word Word document (241 KB- includes checklist, assurance, required documentation and student profile)

Application Checklist - PDF PDF Document (79 KB - checklist only)

Statement of Assurance - PDF PDF Document (74 KB - assurance only)

Required Documentation - PDF PDF Document (52 KB - documentation only)

Student Profile - PDF PDF Document (153 KB - profile only)


Check One:

 

And

Check One:   

 

Check the boxes below to indicate that all required documentation is submitted. 

(see required notification form)

(s)

Or

For students turning 21 during July or August 2012

For students returning in-State:


(Please Type or Print)

Student Name:                                            DOB: /    /               
Recommended Residential Placement:                                                              

Current Educational Placement:_______________________________________

Date of CSE Meeting:       /       /        Disability Classification:                            
STAC # (Continuing Students Only):                                                                      
School District:                                                                                                   
CSE Chairperson:                                                   E-mail:                          
Phone Number:  (       )                                          Fax #:  (       )                 
With consent of parent, has the CSE made a referral to the Office for People With Developmental Disabilities (OPWDD) for eligibility?   __ Yes  __ No  __ N/A.

Note: School districts must complete and submit an application for State reimbursement consistent with these procedures and timelines.  Failure to do so may result in a denial of State reimbursement.  Failure to submit a timely application will result in State reimbursement as of the date the application for reimbursement is received by the New York State Education Department (NYSED).  Regardless of the State’s determination regarding approval of State aid reimbursement, the Board of Education of the sending school district is responsible for a timely placement of the student and is fiscally responsible for the tuition costs as well as the district’s share of maintenance costs.

Last Updated: March 9, 2012