2011-2012 Educable Child Applications

1. Private School Approval Application
   
   
   1. Memo
   2. Directions
   3. School Approval Application
   4. School Calendar (DI-SE-F69)
   5. Data Sheet Instructions (DIR-DI-SE-43B)
   6. Data Sheet (DI-SE-F43B)
   7. Certification Update (DI-SE-F1)
   8. Assurances and Approval Procedure
      
      
2. Educable Child Procedures



3. Applications
   (The entire application package must include the forms or reports as listed. Applications must be the latest revised version posted for the 2011-2012 school year. Please submit the application on the appropriate color of paper as requested. An incomplete application or partial data will result in the application being returned for completion and will delay approval. Make sure all copies of submitted data are legible and current in order to obtain approval. Faxed copies will not be acceptable.)
   
   All eligibilities (initial and re-evaluations) must be obtained from the district in which the student resides. Eligibilities from facilities will not be accepted.
   
   
1. Mississippi Department of Human Services (DHS)
   
   
   1. Application for Financial Assistance (DI-SE-F68) - (Pink)
   2. A copy of the child’s current Determination of Eligibility Report (DER) and a copy of the current Evaluation Report (ER)
   3. A current Individualized Educational Program (IEP) developed in accordance with regulations
   4. Current (within one year) court order/legal document which grants custody of the child to the MS Department of Human Services or other State Agency
   5. A copy of the notarized Assignment of Tuition Reimbursement Form (DI-SE-F9)
   
   
2. Parent-Medicaid
   
   
   1. Application for Financial Assistance (SDE-BSS-F11) - (Blue)
   2. A copy of the child’s current certification by Division of Medicaid which specifies the requirement for inpatient care in an ICF-MR facility or Psychiatric Residential Treatment Facility (PRTF) and the period for inpatient care
   3. A copy of the child’s current Determination of Eligibility Report (DER) and a copy of the current Evaluation Report (ER)
   4. A current Educable Child Form for Parentally Placed Students (Directions)
   5. A copy of the notarized Assignment of Tuition Reimbursement Form (DI-SE-F9)
      
      
3. Parent
   
   
   1. Parent/Guardian Application for Financial Assistance when placing a chi1d with a disability in a private or parochial school (D1-SE-F11) - (Green)
   2. A copy of the child’s current Determination of Eligibility Report (DER) and a copy of the current Evaluation Report (ER)
   3. A current Educable Child Form for Parentally Placed Students (Directions)
   4. A copy of the notarized Assignment of Tuition Reimbursement Form (DI-SE-F9)
      
      
4. School District
   
   
1. Public School District Application for Financial Assistance when placing a student with a disability in a private school/facility(DI-SE-F10) - (Yellow)
2. A copy of the child’s current Determination of Eligibility Report (DER) and a copy of the current Evaluation Report (ER)
3. A current Individualized Educational Program (IEP) developed in accordance with regulations
4. Justification for Placement (DI-SE-F10a)

4. Reimbursement Forms
   1. DHS

      1. First Pay Period
         1. With Transportation Cost
      2. Second Pay Period
         1. With Transportation Cost
      3. Third Pay Period
         1. With Transportation Cost
      4. Fourth Pay Period
         1. With Transportation Cost
      5. Fifth Pay Period
         1. With Transportation Cost
   2. Parent

      1. First Pay Period
      2. Second Pay Period
      3. Third Pay Period
      4. Fourth Pay Period
      5. Fifth Pay Period
   3. Parent-Medicaid

      1. First Pay Period
      2. Second Pay Period
      3. Third Pay Period
      4. Fourth Pay Period
      5. Fifth Pay Period
   4. School District

      1. First Pay Period
      2. Second Pay Period
      3. Third Pay Period
      4. Fourth Pay Period
      5. Fifth Pay Period



5. Invoices
   1. Memo
   2. Invoice Form
   3. Invoice Parent Placement Only


6. Official Drop Form

NOTE:   Forward all forms and reports to the Mississippi Department of Education, Office of Special Education, Attention: Program Coordinator, Educable Child Program, P. O. Box 771, Suite 301, Jackson, MS 39205.
Fax copies will not be accepted.