Educational Services Program Application Checklist

Program Overview
The Educational Services Program is for students with an identified learning disability. Services provided through an IEP, ISP, or 504 plan are onlyadministered through the Educational Services Program. Studentswishing to receiveservices at Saint UrsulaAcademy through these plans must apply for the Educational ServicesProgram when they apply to Saint Ursula Academy. Accommodations will not be available to Saint Ursula Academy students not enrolled in the Educational Services Program.
Admission to the Educational Services Program is limited to ensure that we may provide high-quality services to the students enrolled.
Participation in the Educational Services Program does require an additional fee. For 2017-2018 students in the Educational Services Program are billed an additional $4,620above the school tuition.

DEADLINE: All requests for accommodations and supporting documents (i.e., current IEP, ISP, Accommodation Plan or 504 Plan AND a currentevaluation) must be received byNovember 3, 2017.

A complete application for admission to the Educational Services Program includes:

 / Application for Admission to Saint Ursula Academy’s Class of 2022
 / Educational Services Program Application for the Class of 2022
 / High School Placement Test: Take the test on Saturday, November 18 and indicate that your scoresshould be sent to Saint Ursula Academy.
 / An educational evaluation that has been completed within the past two years. The educational evaluation should consist of the following:
  • Cognitive testing [WISC-III, IV or Woodcock-Johnson-III or IV Cognitive Abilities Test with subtest scores]
  • Educational achievement tests [Woodcock-Johnson-III or IV or the Wechsler Achievement Tests] (Other diagnostic tests, such as the Woodcock Reading Mastery Tests and the Test of Written Language, are helpful.)
  • Description of the presenting problem and history, the functional limitations and specific recommendations for accommodations for class and testing [school-based and standardized]

 / Results of previous educational testing
 / Recommendations from eighth grade teachers and tutor addressing the student's day-to-day skills, work habits, and motivation. Please download and use Teacher Information Form provided.
 / Grade school records including the following:
  • Report cards from 6th and 7th grades and first quarter 8th grade
  • Reports of standardized group achievement tests (e.g. Iowas, ERBs)

Need more information? Interested families are strongly encouraged to talk with Ms. Geri Walsh, Educational Services Program Coordinator. Contact Ms. Walsh at (513) 961-3410 ext. 135, (513) 961-3856 [Fax], or .

Class of 2022 Educational Services Program Application

The Educational Services Program is for students with an identified learning disability. Services provided through an IEP, ISP, or 504 Plan are onlyadministered through the Educational Services Program. Studentswishing to receiveservices at Saint UrsulaAcademy through these plans must apply for the Educational ServicesProgram when they apply to Saint Ursula Academy. Accommodations will not be available to Saint Ursula Academy students not enrolled in the Educational Services Program.

Admission to the Educational Services Program is limited to ensure that we may provide high-quality services to the students enrolled.

Participation in the Educational Services Program does require an additional fee. For 2017-2018, students in the Educational Services Program are billed an additional $4,620 above the school tuition.

All requests for accommodations and supporting documents (i.e., current IEP, ISP, Accommodation Plan or 504 Plan AND a current evaluation) must be received by November 3, 2017.

Student Information (please print)
Last Name / First Name / Middle Name / Preferred Name (Nickname)
Primary Address / City / State / Zip
Primary Phone Number / Email Address
Date of Birth / School Currently Attending
Family Information (please print)
Parent/Guardian name / Relationship to applicant / Parent/Guardian name / Relationship to applicant
Email address / Email address
Home Phone / Work Phone / Home Phone / Work Phone
Cell Phone / Cell Phone
Educational & Diagnostic Information
Student’s diagnosis (e.g. dyslexia, language disability, math disability, written language disability, AD/HD)
Date of initial diagnosis (month and year) / Date of most recent evaluation (month and year)
Who performed the most recent evaluation? (Name of psychologist or school district)

Saint Ursula Academy Educational Services Program Application, page 2
Does your daughter have an ETR (Evaluation Team Report) or evaluation completed by a public school district?
☐Yes ☐No / Public school district completing ETR
Does your daughter have an IEP/ISP (Individual Education Plan) completed by a public school district?
☐Yes ☐No / Public school district completing IEP/ISP
Does your daughter currently receive the Jon Peterson Scholarship? ☐Yes ☐No
Is your daughter in any special programs (e.g., reading clinic, resource room, inclusion model, language therapy, etc.)? Please explain.
Is your daughter receiving special accommodations/modifications (e.g., books on tape, untimed tests, etc.) at her present school? Please explain.
Does your daughter have membership in Learning Ally (formerly Recording for the Blind & Dyslexic)? ☐Yes ☐No
Does your daughter have an AD/HD diagnosis? ☐Yes ☐No / If so, what is the current plan to mitigate her AD/HD’s effect on her ability to function well in school?
Does your daughter take responsibility regarding this plan? Please explain:
Is there anything else you want us to know about your daughter?

Educational Services Program

Teacher Information on Student Learning Characteristics and Performance

This form should be completed by the student’s Tutor (if applicable), her Math and Language Arts Teachers.

Student Name / Date
School
Teacher(s) / Subject(s)

Please list specific strengths in student performance you have observed (behavior and/or academics):

Please list specific weaknesses in student performance you have observed (behavior and/or academics):

Please list instructional techniques that have been most effective for this student:

Please list the most important accommodations/modifications for this student:

Does student complete and turn in homework/projects on time?☐YES ☐NO

Please add any comments on the student’s study habits, social adjustment, motivations, etc.:

Please send completed form to Ms. Geri Walsh via email at , fax to 513-961-3856, or mail to Saint Ursula Academy, 1339 E. McMillan St., Cincinnati, OH 45206

Please print, complete and submit the HSPT Accommodation Formto Ms. Geri Walsh, by Friday, November 3, if you are planning to test at Saint Ursula Academy with accommodations. Saint Ursula Academy will offer:

  • Extended testing time
  • Large print
  • CD recording
  • Scribe