| * required fields |
Student Information
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Student First Name (as listed on birth certificate): *
Please enter student first name! |
Student Last Name (as listed on birth certificate): *
Please enter student last name! |
Student Date of Birth:
* Invalid date format
Please enter your date of birth! |
Student Grade(for 2024/2025 school year)*
Please select your grade
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Address (include Unit/Apartment # if applicable): *
Please enter your address! |
City: *
Please enter your city! |
Zip Code: *
Please enter your zip code!
Invalid zip code |
Parent/Guardian Information
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Parent/Guardian (1) First Name: *
Please enter parent first name! |
Parent/Guardian (1) Last Name: *
Please enter parent last name! |
Parent/Guardian (1) Daytime Phone Number: *
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Invalid Area Code Invalid phone number 2 Invalid phone number 3
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Email Address: *
Invalid email address Please enter your email address! |
Parent/Guardian (2) First Name:
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Parent/Guardian (2) Last Name:
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Parent/Guardian (2) Daytime Phone Number:
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Invalid Area Code Invalid phone number 2 Invalid phone number 3
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Email Address:
Invalid email address |
Home Language Survey
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| Is a language other than English spoken at home? *
If yes what language?
Please provide an answer |
| Does the student have a first language other than English? *
If yes what language?
Please provide an answer |
| Does the student most frequently speak a language other than English? *
If yes what language?
Please provide an answer |
Educational Information and Request for Services
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Eligibility for services – please note, students with 504 plans only are not eligible to receive services through IDEA funding. *
Please select one or more eligibility services
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Request for services from Pinellas County Schools for the 2024/2025 school year. *
Please select one or more services
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Type of school student last attended during the 2023/2024 school year
*
Please choose from the list of private schools
Please select the type of your last attended current year school
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Private school the student is registered to attend for the 2024/2025 school year
*
If the school is not listed, please contact the private school office at (727)793-2704
Please select your next year private school |
Parent Input
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Describe your child's strengths *
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Please describe your child's strength |
Describe your child's success this past year *
characters remaining
Please describe your child's success |
Describe the concerns that you may have about your child. Think about the areas that are most difficult or
challenging for your child (Please limit to 10 sentences or 1000 characters) *
characters remaining
Please describe the concerns that you may have about your child
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Is there any additional information that you would like to share about
your child (Please enter "None" or limit to 10 sentences or 1000 characters)*
characters remaining
Please describe the concerns that you may have about your child
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Authorization Release of Information
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*
By checking this box I confirm I have read the Authorization Release of Information, and hereby authorize the School Board of Pinellas County Florida (PCS)
to send or receive all of the information listed on the form and further grant permission to PCS to have access to my student at school.
You must confirm to submit |
To finalize your request, send a copy of your student’s:
- most recent IEP, SP, or eligibility paperwork
- birth certificate
- physical (including vision and hearing screening)
- immunization records
to moskalczykk@pcsb.org or mail to Private School Office, Bernice Johnson Center, 2929 County Road 193 Clearwater, FL 33759
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