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Extended School Year Services (ESY) - The Special Education Team

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Antonio - page 4<br />

7/1999<br />

Revised 8/2004<br />

Page ____ of ____<br />

EXTENDED SCHOOL YEAR FOR ____________________ (I-15)<br />

_____________________ SCHOOL DISTRICT<br />

Does the child require extended school year (<strong>ESY</strong>) services to receive a free and appropriate<br />

public education (FAPE)?<br />

� Yes � No<br />

If no, explain reasons rejected:<br />

If yes, identify which annual goals, including benchmarks or short term objectives, will be<br />

addressed during <strong>ESY</strong>:<br />

Emerging understanding of decoding/encoding skills related to reading.<br />

Specify all needed services:<br />

I. <strong>Special</strong> <strong>Education</strong><br />

Individualized instruction – Reading-decoding/encoding<br />

skills for CVC words, for reading and writing purpose.<br />

II. Related services<br />

III. Supplementary aids and services - aids, services, and<br />

other supports provided to or on behalf of the student in<br />

regular education or other educational settings<br />

Provision of instructional support packet of materials for<br />

parental use to support <strong>ESY</strong> instruction.<br />

IV. Program modifications or supports for school personnel<br />

that will be provided<br />

Instruction to parents on use of packet<br />

Frequency/<br />

Amount<br />

Two hours<br />

per day<br />

Weekly<br />

One hour<br />

session<br />

Location<br />

Resource<br />

Room<br />

Home<br />

Home<br />

Duration<br />

(beginning and<br />

ending dates)<br />

June 15 -<br />

August 15<br />

June 15 –<br />

August 15<br />

Week of June 9<br />

CESA #9: 1999 Determining <strong>ESY</strong> <strong>Services</strong>, Revised 2004 21

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