Rev. 2015
RESET
PLACE PROGRAM REGISTRATION CHECKLIST
For Office Use Only
SITE: --SELECT--
DATE:
STUDENT:
CLIENT(S)
_
Registration Form
Original to site/copy to client. District Office Approval Codes are required.
Client Tuition/Enrollment Status Form
Fiscal Procedures Form
Financial Responsibility Form
Client Handbook Verification Form
PLACE Program Behavior Policy Form
District School Board of Pasco County Media Release Non-Consent Form - MIS 667
FERPA Form
Subsidized Client Acceptance Form - (If applicable)
(Early Learning Coalition of Pasco and Hernando Counties, Inc.)
Subsidy Eligibility/Rate Certificate - (If applicable)
PEEPS Client Acceptance Form - (If applicable)
DSBPC Employee Application for Discount – (If applicable)
This form must be completed by new clients or those with a break in service. Discount will
be effective upon District Office approval.
School Board Employee Authorized Pick Up Liability Waiver – (If applicable)
ADA Medical Form (If applicable)
Tuition Express ID Code
Approval Number
NBIS (No Break in Service)
Rev. 2015
PLACE Department
www.placeprogram.com
PLACE PROGRAM
Pasco Learning and Activity Centers of Enrichment
REGISTRATION FORM
PLACE Site --SELECT-Student (Full legal name)
Date of enrollment
Preferred Name
Student Address
Student lives with (Full legal name)
Date of Birth
Sex (M/F)
-SELECT-
Grade
Student ID#
Parent/Guardian (Full legal name)
Relationship to student
Address
Home Phone
Work
Mobile
Work
Mobile
E-mail address
Parent/Guardian (Full legal name)
Relationship to student
Address
Home Phone
E-mail address
Is there a custody issue regarding this student?
Is there a court order regarding this student?
NO
NO
NOTE: Florida statute provides that both parents have equal rights and access to their child and his/her records, unless a court order states
differently. Court order(s) should be copied and kept in the child’s record at the PLACE site.
I understand I must maintain health/accident insurance for my child
Specific Food Allergies
Initial
Other Allergies
Please indicate if your child has a qualifying disability, which may require reasonable accommodation(s) in order to participate in this program.
You are entitled to, at no cost to you, the provision of reasonable accommodations. Additional information will be required from your medical
provider regarding the medical diagnosis and subsequent limitations.
□ NO (My child has no qualifying disability) □ YES (My child has a qualifying disability)
In order to better assist in caring for your child, PLACE staff members may want access your student’s educational records or meet with teachers to discuss
participant needs and supports. Although PLACE is not your student's educational institution, and, thus, does not have a “legitimate educational interest” as
defined by FERPA (Family Educational Rights and Privacy Act), we believe that open communication with school staff supports our efforts to contribute to the
community of caring for each participant. By signing the attached FERPA-compliant records release, you give permission to the PLACE staff to obtain and
utilize information gathered through conversation or educational records for the purpose of providing support to your child while attending PLACE.
EMERGENCY CONTACTS (Names/Phone #s)
School Board Employee
□YES
□YES
□YES
□YES
□NO
□NO
□NO
□NO
Authorized to Pickup
□YES
□YES
□YES
□YES
□NO
□NO
□NO
□NO
How did you hear about us? □ Flyer □ Facebook □ Family/Friend □ Newspaper □ Twitter □ Website/Search Engine □ Van □ Other
For Office Use Only:
Registration Paid Date
D.O Approval #_
Ck/M.O. #
Account Key
DISTRIBUTION: Original – Site; Copy – Parent/Guardian
Rev. 2015
PLACE Program
Client Tuition/Enrollment Status Form
Client Name:
Name(s) of Child(ren):
FEE STATUS:
Full-Time (unlimited services)
Before school only (attendance for any portion of the day during a full day program will
require full-time tuition for that week).
After school only (attendance for any portion of the day during a full day program will require
full-time tuition for that week).
Subsidized (unlimited services)
Drop-in (payment due at time of service)
PLACE Staff (hired prior to 7/27/2010)
PEEPS (unlimited services)
Total Weekly Tuition Due: Weekly tuition due from client for all children on this account
(excluding additional charges such as: late fees, late pickup fees, registration fees, etc.)
Effective Date (Pending D.O. Approval)
Site Manager’s Signature
Date
Client’s Signature
Date
FOR OFFICE USE ONLY
Status Change to: FT
ST
Effective Date/Client Initial
New Weekly Tuition Due:
Status Change to: FT
ST
Effective Date/Client Initial
New Weekly Tuition Due:
NOTE: ANY ADDITIONAL CHANGE IN STATUS WILL INCUR AN ADDITIONAL REGISTRATION FEE PER CHILD.
DISTRIBUTION: Original – Site; Copy – Parent/Guardian
Rev. 2015
PLACE Program Fiscal Procedures
Site:
--SELECT--
Primary Payer:
The following fiscal procedures will take effect as of August 24, 2015. Please initial each one after discussing it with the
Site Manager.
TUITION and FEES
Tuition and fees are due in advance of the week’s services, even when the child is not in attendance.
A late payment fee will be assessed if payment of tuition in full and all outstanding fees are not received by 6:00 p.m. on the second
day of program.
All past due balances must be paid in full by the last day of program in the week for which the balances are due to avoid
disabling of and/or terminating the account.
Students will not be permitted to re-enter program until past due balances are paid in full.
A break in service requires new paperwork and payment of registration fee.
Client adjustments will not be issued for late payment of tuition fees, late pick-up or registration.
Changes in fee status will require amending and signing the Enrollment Status Form.
Change in status will not be made if there is any unpaid balance due.
A fee status change may be made two times per school year. Additional status changes will incur an additional
registration fee per child before becoming effective.
The PLACE Program is not responsible for payments sent in students’ backpacks or left at the school offices.
Pasco County Schools utilizes CheckCare to assist in the recovery of all returned checks.
The PLACE Program reserves the right to require payment by Money Order only.
DROP-IN STATUS
If payment for Drop-in service is not received at the time a child is dropped off at program, a late payment fee will be
assessed.
Drop-in service will not be available to any client who owes money to any PLACE Program.
Clients may not reduce status to Drop-in for Winter Break, Spring Break or extended school holidays.
VACATION
Vacation requests and vacation credit will not be granted after the fact. Clients must have a zero balance at the time they
take vacation.
CHECK-IN/CHECK-OUT
Each person authorized to drop off/pick up a registered child must establish and use his/her own personal code or
identifier.
All students must be signed out by 6:00 p.m.
All students must be signed out by 6:00 p.m. Beginning at 6:01 p.m., a late pick- up fee will be assessed, per child,
for every 15 minutes or any part thereof.
SUBSIDIZED CLIENTS
A late payment fee will be assessed if payment of tuition is not received by 6:00 p.m. on the second day of program.
Clients are responsible for payment of additional tuition charges if the child exceeds the three (3) absences granted per
month by their contract with the Early Learning Coalition of Pasco and Hernando Counties, Inc.
Clients are not eligible for vacation credits.
Annual PLACE Program registration will be deferred until the ELC contract ends or there is a change in status.
My signature below indicates that I have read, discussed with the Site Manager and will abide by each of the aforementioned procedures.
_____________________________________________
Primary Payer Signature
Date
Site Manager Signature
Date
DISTRIBUTION: Original – Site; Copy – Parent/Guardian
FINANCIAL RESPONSIBILITY FORM
Payers listed below will have access to all financial information including account statements, information for tax
purposes, and payment receipts. Only the payers listed below will have the ability to make payments at our check-in
screen and online.
Student (Full legal name)
Account Key
(Office Use Only)
Student ID
PLACE Site
--SELECT--
PRIMARY PAYER
Full Legal Name
Date of Birth
(Required)
Relationship to Student
(Required)
Address
Telephone
(Required)
(Required)
Home
Work
(Required)
Mobile
(Required)
(Required)
E-mail address
Signature
Date
(Required)
(Required)
My signature above confirms I am acknowledging and accepting shared Financial Responsibility for this account, if applicable, with the Secondary Payer as indicated below.
SECONDARY PAYER
(Optional)
Full Legal Name
Date of Birth
(Required)
Relationship to Student
(Required)
Address
Telephone
(Required)
(Required)
Home
Work
(Required)
Mobile
(Required)
(Required)
E-mail address
Signature
(Required)
Date
(Required)
My signature above confirms I am acknowledging and accepting shared Financial Responsibility for this account with the Primary Payer as indicated above.
DISTRIBUTION: Original – Site; Copy – Parent/Guardian
Rev. 2015
PLACE PROGRAM
CLIENT HANDBOOK VERIFICATION
My signature indicates that I have received a copy of the PLACE Program Client
Handbook or reviewed the handbook online at www.placeprogram.com and will
abide by all of the policies and procedures.
----------------------------------------------------------------------------------------------
Signature of Client
___________________________________________
Date
DISTRIBUTION: Original – Site; Copy – Parent/Guardian
Rev. 2015
PLACE PROGRAM BEHAVIOR POLICY
PLACE staff are committed to provide a safe, positive and enriching environment for all children in our program. Although the
PLACE Program is a different setting than the regular school day, appropriate behavior is still expected. Please review the
following expectations of appropriate behavior:
1.
Listening and following directions.
2.
Keeping hands, feet, legs and objects to self.
3.
Speaking in a normal tone of voice, in a courteous manner and utilizing acceptable language.
4.
Using materials and equipment appropriately.
5.
Following safety rules.
PLACE staff will use positive behavior management techniques that include:
1.
Guiding children by setting clear, consistent expectations for program behavior.
2.
Redirecting children to a more acceptable behavior or activity.
3.
Using positive reinforcement
4.
Making eye contact and listening when children talk about their feelings and frustrations.
5.
Guiding children to resolve their own conflicts through the use of conflict resolution skills.
PLACE staff will use the following discipline action steps:
1.
Verbal communication to parent/guardian regarding child's behavior.
2.
Written Behavior Notice.
3.
Suspension from program – Serious or repeated behavior problems will result in a 1- 2 day suspension from the program.
4.
Parent Conference with site and/or District Office PLACE staff member(s).
5.
Termination - PLACE will be unable to serve children who display chronically disruptive and/or dangerous behavior.
Chronically disruptive behavior is defined as verbal or physical activity which may include, but is not limited to:
•
•
•
6.
Behavior that requires constant attention from staff.
Behavior that inflicts physical or emotional harm on other children or self.
Behavior that is abusive toward staff and/or non-compliant with the program rules.
If a child's PLACE service is terminated because of a violation of this Behavior Policy, the parent/guardian(s) may seek to
re-enroll their child no earlier than one year from the date of termination. The decision to approve re-enrollment will be
made on a case-by-case basis and may require documentation that the child’s behavior has significantly improved.
PLACE does not discriminate and gives children with disabilities an equal opportunity to participate in all services, which
includes the provision of reasonable accommodations that do not fundamentally alter the program, provided that the child’s
participation does not pose a direct threat to the health or safety of himself or others. If reasonable efforts have been made
and a child continues to pose a direct threat to the health or safety of himself or others, PLACE services may be terminated.
My signature indicates that I have read, understand and will abide by the procedures described above.
_______________________________________________
__________________________
Client Signature
Date
DISTRIBUTION: Original – Site; Copy – Parent/Guardian
DISTRICT SCHOOL BOARD OF PASCO COUNTY
MEDIA RELEASE NON-CONSENT FORM
The District School Board of Pasco County (DSBPC, the District) strives to celebrate the accomplishments of
its students by sharing information with the community. To do this, the District may submit press releases to
local media (newspapers, radio, television, online news blogs) that include student names, student work, student
photographs, and video and/or voice recordings.
In addition, the District may choose to publish and/or display this information in District-sponsored publications,
at various school or public functions, on the District’s local cable channel, website(s) and various social media
channels, or in the school yearbook. While the intent of this practice is to be informative and celebratory, the
District recognizes that concerns may arise regarding a student’s right to privacy.
Pursuant to the Federal Family Educational Rights and Privacy Act (FERPA), school districts are permitted to
release "school directory information" unless parents exercise their right of refusal. Under the FERPA law,
this information could include: student name, residential address, e-mail address, phone numbers,
photographs/images, school locations, field of study, degrees, honors and awards received and participation
in athletics and other activities.
It is the intent and practice of the School District to publish, post, or release ONLY a child’s name, photograph,
audio and/or video recording, displays of student work or other school-related information and ONLY as
related to student achievement (e.g. academic/athletic recognition or award) or student accomplishment (e.g. a
specially selected piece of work).
If you agree to allow the DSBPC to publish and/or display such information about your student for noncommercial purposes and without cost, no action is required.
If you DO NOT grant permission for the District to release your child’s name, photograph, schoolwork, and/or
video or voice recording in the manner stated above, you must complete, sign and return this Media
Release Non-Consent form to your child’s school. Please note that the Media Release Non-Consent Form
is available in the administrative office of your child’s school and on the District web site, and a signed form is
considered valid for one (1) school year.
By signing and returning this form to my child’s school, I formally state that I DO NOT grant permission to the
District School Board of Pasco County to release my child’s name, photograph, audio and/or video recording,
or displays of work to the media; to publish information about my child’s accomplishments or achievements in
District-sponsored publications; or to display such information on the District’s local cable channel, website(s),
various social media channels, in the school yearbook, or at school or public functions during the current
school year.
Last Name of Student
First Name
Student #
Grade
School
--SELECT--
I understand fully the conditions set forth in this document.
Name of Parent or Guardian (Please Print)
Signature of Parent or Guardian
Date
Contact Phone Number
DISTRIBUTION: Original – Site; Copy – Parent/Guardian
PLACE Department
Mary Grey, Director
813/ 794-2180
Fax: 813/ 794-2487
727/ 774-2180
TDD: 813/ 794-2484
352/ 524-2180
E-Mail: [email protected]
FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA) REQUEST TO
RELEASE/ACCESS STUDENT RECORDS
I,
, (Name of parent of minor student), HEREBY REQUEST that the School
Board of Pasco County, its employees, agents, and assigns (hereinafter SCHOOL BOARD), provide release of student
records, for:
(Name of Student) which are in
possession of the SCHOOL BOARD, to Pasco Learning & Activity Centers of Enrichment (PLACE).
I understand that I can limit the SCHOOL BOARD'S release of records to certain specified records. I wish to have the
SCHOOL BOARD
give access to and/or communicate regarding all student records in its possession OR
only
allow access to and/or communication related to
.
If the "all student records" option is chosen, I understand that the records provided may include materials that are not
student records, or that may otherwise be confidential, including but not limited to criminal records, whether student was
an offender or victim of any type of crime.
I further understand that all such records may be confidential under Federal Law and Florida Law, including, but not
limited to §1002.22, Florida Statutes and 20 U.S.C.A. § 1232g, and I waive all rights of confidentiality as to this request,
thereby allowing SCHOOL BOARD to openly communicate with the PLACE staff,
The reason for this release of records is to allow the PLACE staff to access student educational records or meet with
teachers to discuss participant needs and supports.(20 U.S.C.A. 1232g(b)(2)(A) requires the requestor to specify the
reason for the request for release).
I agree to release, hold harmless, and indemnify the SCHOOL BOARD for any and all damages or claims arising out of
the SCHOOL BOARD’S compliance with my request to provide access to my student’s records to the PLACE program.
Parent/Guardian (or eligible student)
Date
Witness
Date
DISTRIBUTION: Original – Site; Copy – Parent/Guardian
Rev. 2015
PLACE PROGRAM SUBSIDIZED CLIENT
ACCEPTANCE FORM
As a client receiving subsidy form the Early Learning Coalition of Pasco
and Hernando Counties, Inc., I understand that:
• I am not entitled to vacation credit in the PLACE Program. In lieu
of vacation credit, the PLACE Program will defer the annual
registration fee.
• I am responsible for payment of additional tuition charges if my
child exceeds the three (3) absences per month by my contract
with the Early Learning Coalition of Pasco and Hernando Counties,
Inc.
• I am responsible for notifying the Site Manager of any changes in
my ELC Contract.
• I am responsible for payment of late fees that will be assessed if
payment of tuition is not received by 6:00 p.m. on the second day
of program or if I fail to pick my child(ren) up by 6:00 p.m.
My signature indicates that I have read, understand and will abide
the procedures described above.
Client Signature
Date
DISTRIBUTION: Original – Site; Copy – Parent/Guardian
Rev. 2015
PLACE PROGRAM
PEEPS
CLIENT ACCEPTANCE FORM
I understand that as a client of the PEEPS Program, the PLACE
Program will receive a subsidy for payment of weekly tuition. In
lieu of this, the PLACE Program will expect clients to be
responsible for the following charges, if accrued.
•
A charge for late pick-up in the amount of $15.00 per
child for every 15 minutes or any part of that time
past 6:00 p.m.
My signature indicates that I have read, understand and will
abide by the policy described above.
PEEPS Client Signature
Date
DISTRIBUTION: Original – Site; Copy – Parent/Guardian
Rev. 2015
Pasco Learning & Activity Centers of Enrichment
Medical Certification of Student’s ADA Qualifying Impairment
Parents/Guardians requesting a reasonable accommodation pursuant to the Americans with Disabilities Act of 1990 are
required to have an appropriate health care provider complete the following form certifying that the student qualifies to
receive an accommodation. This information is treated confidentially, is not maintained in the student’s main file, and
will be used only by authorized individuals with direct need to know. Please return this form to:
ATTN: Sandy May, Equity Manager
District School Board of Pasco County
7227 Land O’Lakes Blvd.
Land O’Lakes, FL 34638 OR
Fax: (813) 794-2119
Name of Student Requesting ADA accommodations:
First:
Last:
DOB:
As it relates to this request for ADA accommodation(s) only, I authorize this health care provider to submit accurate and
complete information and communicate, verbally and/or in writing, to the PLACE staff regarding the diagnosed medical
condition and my request for reasonable accommodation(s).
Parent Signature:
Date:
____________________________________________________________________________________________
THIS SECTION TO BE COMPLETED AND CERTIFIED BY HEALTHCARE PROVIDER:
Name of Healthcare Provider: __________________________________________________
Specialty/Type of Practice:
Office Address:
________________________________________________________________________
Office Phone: _______________________
__
Office Fax: ______________________
1. In your professional judgment, does this individual have a physical impairment that is a physiological disorder or
condition, cosmetic disfigurement, or anatomical loss? Y or N
1-3
2. In your professional judgment, does the individual have a mental impairment that meets the following
d e f i n i t i o n : “Any mental or psychological disorder such as mental retardation, organic brain syndrome,
emotional or mental illness, and specific learning disabilities?” Y or N
3. Please state the patient’s diagnosis and describe the medical facts that support your certification:
4. When did symptoms first appear?
Reported symptoms:
5. Under ADA regulations, major life activities are described as activities that an average person can perform with
little or no difficulty. The regulations do not offer an exhaustive list but mention the following examples: sitting,
standing, walking, speaking, breathing, seeing, hearing, learning, working, caring for oneself, performing manual
tasks, lifting, bending, reading, thinking, communicating, concentrating, and interacting with others.
In your professional judgment, does this student have an impairment that limits one or more major life activities
according to this definition? Y or N
If yes, please describe
6. The limitation to major life activities must be substantial under the regulations: “An impairment is substantially
limiting if it prohibits or significantly restricts an individual’s ability to perform a major life activity as compared
to the ability of the average person in the general population to perform the same activity.” There are three
factors to consider in determining whether an impairment is substantially limiting:
a. Does the nature and severity of the impairment make it substantially limiting? Y or N
b. Does the anticipated duration of the impairment make it substantially limiting? Y or N
c. Does/Will the impairment have a long-term impact that prohibits or significantly restricts the ability to
perform a major life activity? Y or N
If yes to any of the above, please explain
7. If you believe the individual has a disability that substantially limits the individual’s ability to perform one
or more major life functions, in your professional opinion, can the individual participate in the Pasco
Learning & Activity Centers of Enrichment (PLACE) before and after-school program without direct threat
to their own health and safety and/or the health and safety of others in the program? Y or N
8. Is/Are reasonable accommodation(s) required to enable the individual to participate in the
program? Y or N
If yes, what is the specific activity that requires reasonable accommodation(s)?
2-3
Please suggest reasonable accommodation(s) which should be considered that would specifically and directly
address/ameliorate the substantial limitation and enable the student to successfully participate in the program,
without fundamentally altering the services provided:
9.
Please provide any additional information that you feel would be useful in evaluating the student’s
medical condition:
Signature of attending physician:
Printed name of attending physician:
Date:
3-3