* required fields
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1. New or Returning Students *
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2. First Name: *
Please enter your first name! |
3. Last Name: *
Please enter your last name! |
4. Grade: *
Please select your grade
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5. Date of Birth:
* Invalid date format
Please enter your date of birth! |
6. Parent/Guardian First Name: *
Please enter parent first name! |
7. Parent/Guardian Last Name: *
Please enter parent last name! |
8. Daytime Phone: *
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Invalid Area Code Invalid phone number 2 Invalid phone number 3
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9. Mobile Phone:
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Invalid Area Code Invalid phone number 2 Invalid phone number 3
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10. Address: *
Please enter your address! |
11. City: *
Please enter your city! |
12. State: *
Please select your state! |
13. Zip Code: *
Please enter your zip code!
Invalid zip code |
14. Email Address: *
Invalid email address Please enter your email address! |
15. Last Year’s Private School Name (for returning students only):
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16. School Attended Last Year: *
Please enter your last year's school! |
17. County where school was located: *
Please enter your school's county! |
18. Last public school attended: *
Please enter your last public school attended! |
19. Date of Withdrawal:
* Invalid date format
Please enter date of withdrawal |
20. Current Year Private School Name: *
Please select your current year private school
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21. Services You Are Requesting from Pinellas County Schools This Year: *
Please select one or more services
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22. Did your child have a 504, IEP or SP? *
Please select one
If you are not sure click for an example of each
IEP
504
SP
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23. Is a language other than English spoken at home? *
If yes what language?
Please provide an answer
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24. Does the student have a first language other than English? *
If yes what language?
Please provide an answer
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25. Does the student most frequently speak a language other than English? *
If yes what language?
Please provide an answer
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Parent Input
Your input is very important to developing a plan that meets your child’s special needs. Please take a few minutes to think about what makes
your child unique. Share with us any activities, learning experiences or goals that have been successful in the past.
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26. Describe your child's strengths *
Please describe your child's strength
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27. Describe your child's success this past year *
Please describe your child's success
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28. 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) *
Please describe the concerns that you may have about your child
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29. Is there any additional information that you would like to share about your child (Please limit to 10 sentences)
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30. How did you hear about the PPPSSD Program? *
Please provide an answer
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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
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By submitting this application, and if this is the first time you have requested services from the PPPSSD Program,
you must mail a copy of your child’s birth certificate, up-to-date immunization and school physical form to:
Private School Office
2929 County Road 193
Clearwater, FL 33759
If you previously received services from the PPPSSD Program, thank you for submitting for the current school year.
*
You must agree to submit
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