State of Alaska, Sample ILP - Individual Learning Plan

STUDENT INFORMATION 2013-2014 School Year

SAMPLE STUDENT
Last Name First Name MI Suffix Date of Birth Primary Phone Student Email
PARENT INFORMATION

Names(s) Mailing Address City Zip Parent Email

IMPORTANT – Parent/guardian and student notice of rights and responsibilities regarding program enrollment
1. All parents and students in correspondence programs have the same right to access the district appeal process as parents and students in other
district programs (4 AAC 33.421). This includes, but is not limited to, special education (4 AAC 33.432).
2. All enrolled students, including part-time students, are required to participate in statewide student assessments (4 AAC 33.421).
3. Courses receiving an “incomplete” may not be counted towards credit for enrollment requirements (4 AAC 33.426).
4. Parents must disclose enrollment for all other education institutions, including private schools, to ensure the student is not concurrently
enrolled in a substantially similar course (4 AAC 33.430).
5. All textbooks and other curriculum materials must be aligned with state standards, comply with regulatory requirements, and be reviewed by
a certified teacher (4 AAC 33.421).
6. All non-expendable materials remain the property of the school district and must be returned to the district (4 AAC 33.422).
7. All expenditures related to the student must be directly tied to a specific course with a need addressed in the ILP (4 AAC 33.422).
8. Monthly contact with the parent/student is required (4 AAC 33.421).
9. A quarterly review of the student’s progress with the parent/student is required (4 AAC 33.421).
10. A grade or other determination of course progress as determined by the certified teacher responsible for the course (4 AAC 33.421).
11. This plan may provide for review and consideration of any recommendations submitted by the parent or student (4 AAC 33.421).
Your signature indicates: you are aware of this information; you accept responsibility for ensuring your student is aware of their rights and
requirements; you agree to all requirements; and you confirm that the information provided is true and accurate the best of your knowledge.

Parent Signature Parent Signature Date Contact Teacher Signature Contact Teacher Name (Print)

DISTRICT USE SPECIAL EDUCATION

State of AK ID: FTE: 1 .75 .5 .25 IEP Expiration Date:

Computer Issued: Yes No ESER Expiration Date:
Out of District: Yes No Siblings Enrolled: Yes No Disability:
Dual Enrollment: Yes No Graduation Track: Yes No Assessment Accommodations:

NOTE:
This ILP is a sample form. The specific content and format are at the district's discretion.
SAMPLE STUDENT 2013-2014
SUBJECT: ½ Credit Fall ½ Credit Spring Other:
Curriculum Materials:
Please indicate titles(s) , publisher;
Add the material level (if specific).
Include texts, videos, tutoring, etc. Estimated Cost:
Source of Credit:
Vendor: Parent Designed Course District Course Teacher of Record:
Topics:
This should include all major
topics to be covered in the course.
Method of Assessment:
Quizzes/ Tests Learning Journal Oral Review/Presentations Guided Practice Portfolio Projects
Other:
Planned Activities:
Describe the activities planned
and any facilities, tutoring,
special materials, etc. to be used.
Grading Scale/Goals:
Explain what the student will be
able to do as a result of the
course. Include special tasks.

SUBJECT: ½ Credit Fall ½ Credit Spring Other:

Curriculum Materials:
Please indicate titles(s) , publisher;
Add the material level (if specific).
Include texts, videos, tutoring, etc. Estimated Cost:
Source of Credit:
Vendor: Parent Designed Course District Course Teacher of Record:
Topics:
This should include all major
topics to be covered in the course.
Method of Assessment:
Quizzes/ Tests Learning Journal Oral Review/Presentations Guided Practice Portfolio Projects
Other:
Planned Activities:
Describe the activities planned
and any facilities, tutoring,
special materials, etc. to be used.
Grading Scale/Goals:
Explain what the student will be
able to do as a result of the
course. Include special tasks. Add additional pages as necessary
SAMPLE STUDENT 2013-2014
QUARTERLY PROGRESS REPORTING
Date Completed Completed By Notes Follow-Up Required?
1st Quarter Date:

2nd Quarter Date:

3rd Quarter Date:

4th Quarter Date:

MONTHLY CONTACT LOG

Date Completed Completed By Notes Follow-Up Required?
SEP Minimum of one contact per month is required

OCT

NOV

DEC

JAN

FEB

MAR

APR
SAMPLE STUDENT 2013-2014

INVENTORY OF NON-CONSUMABLE ITEMS

Item Related Course ID # Condition OUT Condition IN Date Returned
SAMPLE STUDENT 2013-2014
DUAL ENROLLMENT - If the student is enrolled in any other public education program this form must be completed.
School Name: Address:
Phone Number: Fax Number: City: Zip:

This section must be completed by the other public education program administrator
Please indicate the FTE your district is declaring for the ADM report: .75 .5 .25
Please list subjects the student is taking with your school district:
Credit Hours
1.
2.
3.

Signature Printed Name Title Date Completed

This section must be completed by the Parent and assigned Certified Teacher
Please indicate the FTE the Correspondence Program is declaring for the ADM report: .75 .5 .25
Please list subjects the student is taking with this Correspondence Program:
Credit Hours Check for Previous Courses
1.
2.
3.
4.
5.
6.

PRIVATE SCHOOL – If the student is enrolled in a private, non-public funded education institution, this section must be completed
School Name: Address:
Phone Number: Fax Number: City: Zip:
Please list subjects the student is taking with this private, non-public funded education institution:
Credit Hours Check for Similar Courses
1.
2.
3.
4.
5.
6.