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Student Information
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Student First Name (as listed on birth certificate): *
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Student Last Name (as listed on birth certificate): *
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Student Date of Birth:
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Student Grade(for 2024/2025 school year)*
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Address (include Unit/Apartment # if applicable): *
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City: *
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Zip Code: *
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Parent/Guardian Information
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Parent/Guardian (1) First Name: *
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Parent/Guardian (1) Last Name: *
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Parent/Guardian (1) Daytime Phone Number: *
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Email Address: *
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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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Email Address:
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Home Language Survey
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| Is a language other than English spoken at home? *
If yes what language?
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| Does the student have a first language other than English? *
If yes what language?
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| Does the student most frequently speak a language other than English? *
If yes what language?
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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. *
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Request for services from Pinellas County Schools for the 2024/2025 school year. *
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Type of school student last attended during the 2023/2024 school year
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Private school the student is registered to attend for the 2024/2025 school year
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If the school is not listed, please contact the private school office at (727)793-2704 |
Parent Input
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Describe your child's strengths *
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Describe your child's success this past year *
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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) *
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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)*
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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.
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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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