Specialized Instructional Services (sis) for Voluntary Prekindergarten Children with Disabilities



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Specialized Instructional Services (SIS)

for Voluntary Prekindergarten Children with Disabilities

Specified SIS Providers

DOE Form VPK-SIS1
This form must be filled out completely, including original signature on last page. Appropriate and complete documentation (see section B. below), must accompany this form.
A. Contact information

Name of agency head: Click here to enter text.

Name of Contact Person: Click here to enter text. Title: Click here to enter text.

Mailing Address: Click here to enter text.

City: Click here to enter text. State: Click here to enter text. Zip Code: Click here to enter text.

Telephone Number: Click here to enter text. Fax Number: Click here to enter text.

Email address: Click here to enter text. Organization Website: Click here to enter text.
B. Service Provided

Please check the appropriate box below and attach documentation of the applicable credential to this form for processing.

Listening and Spoken Language Specialist™ certified by the Alexander Graham Bell Academy for Listening and Spoken Language

Board Certified Behavior Analyst certified by the Behavior Analyst Certification Board® pursuant to Rule 65G-4.0011, F.A.C.
C. Applicant Information

Check the category(ies) that best describes the applicant’s organization:

Individual

For-profit company

Non-profit organization

Community based/faith-based organization

Institution of higher education

Other:Click here to enter text.
D. Delivery Model and Services

Check all that apply.

Check the group size served for each delivery model selected.

Individual services

Small group (group size two to five students per provider)

Large group (group size six to ten students per provider)

Ability to communicate languages other than English

Spanish

Haitian Creole

Other (identify): Click here to enter text.


Times offered: Click here to enter text.
E. County/Counties to be Served

Baker

Bay


Bradford

Brevard


Broward

Calhoun


Charlotte

Citrus


Clay

Collier


Columbia

Dade


Desoto

Dixie


Duval

Escambia

Flagler

Franklin

Gadsden

Gilchrist

Glades

Gulf


Hamilton

Hardee


Hendry

Hernando

Highlands

Hillsborough

Holmes

Indian River



Jackson

Jefferson

Lafayette

Lake


Lee

Leon


Levy

Liberty


Madison

Manatee


Marion

Martin


Monroe

Nassau


Okaloosa

Okeechobee

Orange

Osceola


Palm Beach

Pasco


Pinellas

Polk


Putnam

St. Johns

St. Lucie

Santa Rosa

Sarasota

Seminole

Sumter

Suwannee



Taylor

Union


Volusia

Wakulla


Walton

Washington



I, THE UNDERSIGNED, CERTIFY that all of the information provided herein is true and accurate, to the best of my knowledge. In the instance that I am signing on behalf of an organization, I am authorized to act on behalf of the organization.

_____________________________________ Click here to enter text.



Original Signature of Applicant Date signed

(see Notes below)


Click here to enter text.

Printed Name
Click here to enter text. Click here to enter text.

Name of Agency/Company/Group Title of Signing Agent
Notes:

  1. Printed name and original signature must match.

  2. Use blue ink for original signature.

  3. "By", "for," or initials will not be accepted.

  4. Rubber stamp signatures will not be accepted.


Before sending, please ensure:

  • DOE Form VPK-SIS1 includes an original signature in blue ink.

  • Appropriate documentation for items required in Section B is attached.


Please submit DOE Form VPK-SIS1 to:

Florida Department of Education

Just Read, Florida! and the Office of Early Learning

Attn: VPK-SIS Form Processing

325 W. Gaines Street, Suite 514

Tallahassee, FL 32399


This application will be processed within four weeks of receipt.

Florida Department of Education

Just Read, Florida! and the Office of Early Learning

325 W. Gaines Street, Suite 514

Tallahassee, FL 32399

Toll Free: 1-866-447-1159 • earlylearning@fldoe.org


Rule 6A-6.03033 (Effective July 2012)



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