Parentally Placed Private School Students with Disabilities (PPPSSD) Form


* required fields

1. New or Returning Students *
2. First Name: *
3. Last Name: *
4. Grade: *
5. Date of Birth: *  
6. Parent/Guardian First Name: *
7. Parent/Guardian Last Name: *
8. Daytime Phone: *
    - -
9. Mobile Phone:
    - -
10. Address: *
11. City: *
12. State: *
13. Zip Code: *  
14. Email Address: *
15. Last Year’s Private School Name (for returning students only):
16. School Attended Last Year: *
17. County where school was located: *
18. Last public school attended: *
19. Date of Withdrawal: *  
20. Current Year Private School Name: *

21. Services You Are Requesting from Pinellas County Schools This Year: *      

22. Did your child have a 504, IEP or SP? *
    If you are not sure click for an example of each
      IEP       504       SP

23. Is a language other than English spoken at home? *   
      If yes what language?

24. Does the student have a first language other than English? *   
      If yes what language?

25. Does the student most frequently speak a language other than English? *   
      If yes what language?
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.

26. Describe your child's strengths for all four questions (Please limit to 10 sentences) *
27. Describe your child's success this past year *
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) *
29. Is there any additional information that you would like to share about your child (Please limit to 10 sentences)
30. How did you hear about the PPPSSD Program? *
Authorization Release of Information
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.

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:
    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.