Administrator's Contact Information

Administrator's Name*

Synagogue or Supplemental Religious School Name*

Administrator's Email*

Phone Number*

Address*

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Application

How many children with individualized learning and special needs will you be serving in the 2023-2024 school year?*

Are all the children in grades K through 12, or range in the ages from 5 to 18?*

• Yes
• No

Please list the number of children in each grade level*

Are the children enrolled in a supplementary religious school program or would they be enrolled if special services were available?*

• Yes
• No

Please Explain*

Do the children have an IEP (Individual Educational Plan or Section 504 Plan) in their public school setting (i.e.: those children with moderate to severe needs for whom an intervention such as an aide, tutor, or interpreter will enable the child to benefit from the religious school program)?*

• Yes
• No

Please explain.*

Please describe the support that has been provided during the current or most recent school year*

Please describe the support that has been provided during the previous school year along with your expected needs for the upcoming school year. (including summary and cost) . If you already submitted a summary for last year, please resend that along with this year’s request.*

Submit

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