SUCCESS IN SCHOOL PLAN

CORE TEAM: (INCLUDE CONTACT INFORMATION)

Classroom Teacher: Phone: email: School point person: Phone: email: Caseworker: Phone: email: Caregiver/Group Home Phone: email: Other legal guardian(s): Phone: email: Others supporting success: (check if applicable and list appropriate support people) Name: Phone: email: Name: Phone: email: Name: Phone: email:

need Aboriginal representation ____________________________________________________________________________________ Young Person’s aspirations and views of needs/supports/mentor required:

____________________________________________________________________________________ Young Person’s interests, hopes, dreams, friends/important people and activities:

Child/Youth’s Name:

School Year: Grade: ACYS Status: ____________________________________________________________________________________ School: CFSA Office:

____________________________________________________________________________________

Date of Success in School Plan:

SUCCESS IN SCHOOL PLAN1 April 2018

Name: Address:Telephone:

Date of Birth:

Teacher:Caseworker:

School point person:CSFA Office Manager:

need interpreter: language

yyyy

ASN Number:

mm dd

yyyy mm dd

Postal Code:

Educational Needs: (check all that apply)

above

No identified Special Education needs

below Grade Level

Assessment: Awaiting Concerns Apparent

Receiving supports/modification

____________________________________________________________________________________ Attendance: (attach record)

problems

___________________________________________________________________________________ Suspension or expulsion:

____________________________________________________________________________________ Attachments: (indicate applicable documents attached)

Attendance Record Timetable/course list

Individual Program Plan

Delegation of Authority

Report Card

SUCCESS IN SCHOOL PLAN2 April 2018

Individual Program Plan in place

acceptable

If yes, please provide details, including length of time:

Special Needs identified

Undergoing

Describe briefly:

Describe:

No Yes

Other documents, describe:

Generally achieves at

Review summary: (minimum one-review, add other sections as necessary) NOTE: confirm confidentiality agreement at each review – see signature page

exceeding achieving not achieving expectations

____________________________________________________________________________________ Challenges and plans to address them:

___________________________________________________________________________________

exceeding achieving not achieving expectations adjustment to action plan required (see attached amendments) ____________________________________________________________________________________Successes:

____________________________________________________________________________________ Challenges and plans to address them:

Next Success in School Plan review: (or as needed due to transition or challenges)

Date: Time: Location:

Date: Time: Location: ____________________________________________________________________________________ Transition Plan (as required): Purpose, new core team, contingency arrangements, etc.

SUCCESS IN SCHOOL PLAN3 April 2018

Date:

Date:yyyy mm dd

adjustment to action plan required (see attached amendments)____________________________________________________________________________________

Successes:

yyyy mm dd

yyyy mm dd

yyyy mm dd

Contact and Responsibility Agreement Communication between the individuals involved with ______________________________________ will be guided by the following procedures depending on the circumstance. Indicate who will be contacted in the following circumstances:

Caregiver

Caregiver School point person Others:

Caregiver

Caseworker will contact (as appropriate)

Others:

School will contact:

Caregiver Caseworker

School will contact:

Caseworker Caseworker

School will contact:

Caseworker

* Celebration of successes and accomplishments:

* Change in child status or placement with ACYS:

* Sudden change in school status: (eg. Suspension or expulsion, special education placement)

* Critical incident at school: (eg. Injury, attendance/academic crisis, severe behavior/safety incident)

* Emergent school events: (eg. permissions for field trips or assessments, special reports)

* Day-to-day school events: (class and school events, homework, daily attendance, typical child development)

SUCCESS IN SCHOOL PLAN4 April 2018

Caseworker will contact (as appropriate)

Caregiver

Authority assigned to:

Caregiver

Caseworker Parent (when applicable) Others:

Parent (if applicable)

Caseworker Parent (if applicable)

Parent (if applicable) Others:

Caregiver

(eg. School based awards, special events class performances, extra-curricular recognition, academic or social sccomplishments)School personnel will contact:

Review of the Success in School Plan or Transition Plan may be indicated

CFSA staff will contact:

Review of the Success in School Plan may be indicatedSchool will contact:

Review of the Success in School Plan may be indicated

Review Date:

_______________________________ _________________________________ _______________________________

All participants sign at internal development and each subsequent review (pre-planned/emergent) to indicate agreement with the plan and the roles with carrying it out, as well as to indicate understanding that due to the sensitivity of the information shared at the meeting to develop and review this plan, all information shared will be kept confidential.

Core Team:

Name: Development Signature: Review Review

_____________________ ________________________ _________________________ ________________________ child/youth signature child/youth signature child/youth signature child/youth

_____________________ ________________________ _________________________ ________________________ caregiver signature caregiver signature caregiver signature caregiver

_____________________ ________________________ _________________________ ________________________ teacher signature teacher signature teacher signature teacher

_____________________ ________________________ _________________________ ________________________ caseworker signature caseworker signature caseworker signature caseworker

_____________________ ________________________ _________________________ ________________________ school point person signature signature signature

school point person school point person school point person

_____________________ ________________________ _________________________ ________________________ signature signature signature other legal guardian or other legal guardian or other legal guardian or

other legal guardian or support person

support person support person support person

SUCCESS IN SCHOOL PLAN5 April 2018

Signatures of those involved and dates:

Development Date: Review Date:

yyyy mm dd yyyy yyyymm mmdd dd

Success in School Plan for ____________________________________ Date of Plan:

Domain (suggest holistic view)

Current Situation (adjust at each review)

Support Arrangements (what, who when)

Successes/Results (date)

Social (friendship, behaviour,

relationships, emotional)

Academic (course work, subject areas,

homework, future goals)

Physical (health and well-being,

sports, nutrition, healthy choices)

Cultural (creative, spiritual, heritage,

language and culture)

Other (special interests, unique needs, personal pursuits)

6 SUCCESS IN SCHOOL PLAN April 2018

yyyy mm dd