REPORTING OF OUTOFSTATE NONPUBLIC NONSECTARIAN SCHOOLAGENCY PLACEMENT CALIFORNIA EDUCATION

1

Placing Agency Information

Placing Agency:      

Address:      

City:      

State:      

ZIP Code:      

Contact Person :      

Telephone:      

Signature:      

2.

Student Information

Student ID# :      

Date of Birth:      

4..

Nonpublic School/Agency (NPS/A) Information

NPS/A Name:      

Is the NPS/A currently California-certified? Yes No (Requires Waiver)

Address:      

City:      

State:      

ZIP Code:      

Contact Person:      

Telephone:      

Date of Placement:      

For School Year(s):      

Anticipated Date of Return to a California Placement:      

5.

Out-of-State Pupil Placement and Costs

Note: Continue description in Item 6. Use additional sheets, if necessary.

Check appropriate box

Full Day NPS Placement

Contract Cost:      

Partial Day NPS Placement

Contract Cost:      

Residential NPS Placement

Contract Cost:      

Full Day NPA Placement

Contract Cost:      

Partial Day NPA Placement

Contract Cost:      

6.

Describe Out-of-State Pupil Placement and Costs

     

7.

Related Services. List and identify cost of related service(s). Use additional sheets, if necessary.

     

8.

Describe the efforts to locate an appropriate public school, NPS/A, or a combination, thereof, within the State of California.