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REF-5276. 1 November 1 2010 Los Angeles Unified School District Division of Special Education ATTACHMENT E-2 SCHOOL USE ONLY ESY STUDENT INFORMATION FORM DIRECTIONS IEP team is to complete this form for each student eligible for ESY and whose parent has completed and signed an Enrollment/Emergency Information form. Provide a copy of this form current IEP and the Enrollment/Emergency form to your site Administrator. STUDENT Print Last First ESY Eligibility IEP FAPE Part 1 Yes Initial Grade No Birth date ESY PERIOD SUMMER 20 School of Attendance Location Code School of Residence Curriculum Primary Eligibility Current Special Education Program Local District Gen* Ed. Standards-Based SDP/ RSP Alternate Curriculum Gen* Ed w/ inclusion Program IEP Team Recommended ESY Program LUNCH Free Reduced SDP-Mild/Moderate SDP-Moderate/Severe Full Student requires the following Related Services during ESY must be specified on current IEP DIS/Related Services Check all that apply Adapted PE Occupational Therapy OT Audiology OT Clinic DIS Counseling Specialized Nursing Services Deaf/ Hard of Hearing Speech Language LAS Orientation Mobility KIT Center BII/District Visual Impairment BII/NPA Physical Therapy Other TRANSPORTATION as indicated in IEP None School-to-School Home-to-School ASSISTIVE TECHNOLOGY and LOW INCIDENCE EQUIPMENT as indicated on IEP PROGRAM SUPPORT Health Care Asst. HCA Bus Support HCA Name EN List current special education teacher s providing direct instruction/service secondary programs only SESAC Teacher Print Date Assignment of teachers and classroom support personnel will follow bargaining unit contractual guidelines. STUDENT Print Last First ESY Eligibility IEP FAPE Part 1 Yes Initial Grade No Birth date ESY PERIOD SUMMER 20 School of Attendance Location Code School of Residence Curriculum Primary Eligibility Current Special Education Program Local District Gen* Ed. Standards-Based SDP/ RSP Alternate Curriculum Gen* Ed w/ inclusion Program IEP Team Recommended ESY Program LUNCH Free Reduced SDP-Mild/Moderate SDP-Moderate/Severe Full Student requires the following Related Services during ESY must be specified on current IEP DIS/Related Services Check all that apply Adapted PE Occupational Therapy OT Audiology OT Clinic DIS Counseling Specialized Nursing Services Deaf/ Hard of Hearing Speech Language LAS Orientation Mobility KIT Center BII/District Visual Impairment BII/NPA Physical Therapy Other TRANSPORTATION as indicated in IEP None School-to-School Home-to-School ASSISTIVE TECHNOLOGY and LOW INCIDENCE EQUIPMENT as indicated on IEP PROGRAM SUPPORT Health Care Asst. Standards-Based SDP/ RSP Alternate Curriculum Gen* Ed w/ inclusion Program IEP Team Recommended ESY Program LUNCH Free Reduced SDP-Mild/Moderate SDP-Moderate/Severe Full Student requires the following Related Services during ESY must be specified on current IEP DIS/Related Services Check all that apply Adapted PE Occupational Therapy OT Audiology OT Clinic DIS Counseling Specialized Nursing Services Deaf/ Hard of Hearing Speech Language LAS Orientation Mobility KIT Center BII/District Visual Impairment BII/NPA Physical Therapy Other TRANSPORTATION as indicated in IEP None School-to-School Home-to-School ASSISTIVE TECHNOLOGY and LOW INCIDENCE EQUIPMENT as indicated on IEP PROGRAM SUPPORT Health Care Asst. HCA Bus Support HCA Name EN List current special education teacher s providing direct instruction/service secondary programs only SESAC Teacher Print Date Assignment of teachers and classroom support personnel will follow bargaining unit contractual guidelines.

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