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Confidential SE-001(98

Page _____ of _____
Bartow County School System
Individual Education Program
Form A
Date: ___________________________

Student's Name: ________________________________ DOB: __________ Age: _____ Grade: _________
FTE: _________________________________________ School: _____________________________________
Parent/Legal Guardian: __________________________________________ Phone: W/H __________________
Address: ___________________________________________________________________________________
Street City ZIP

Committee Members Present
Name/Title Name/Title

LEA Representative

Special Considerations
Special Transportation: No o Yes o (If yes, complete Special Transportation Data Form)
Physical Education: Regular: o Adaptive o (Adaptive PE objectives must be included)
Extended School Year - Committee will meet to consider ESY Services by (date) __________________________
Check one at o Extended School Year Services Recommended (Attach Addendum)
ESY Meeting o Extended School Year Services Not recommended (Attach Addendum)

General Education: General curriculum in which the student will participate without special education services:

Recommended Special Education and/or Related Services:
Service/Program Area Start/End Dates Hours Per Week

Summary of Hours Medical Concerns/Limitations
Total hours weekly of Regular Education o No o Yes Explanation: ___________________
Total hours weekly of Special Education ___________________________________________
Total hours weekly o Medically Fragile (Attach Medical Fragile Report)

This is to certify that I was invited to participate in the writing of this I.E.P. and that I understand its contents. Due
process rights and procedures have been explained and I have been provided a copy of these rights. I understand
that a copy of this I.E.P. will be given to me.

__________________________________________________ _________________________________
Parent/Legal Guardian Date
White – Student Folder Yellow – Central Files Pink - Parent