Form Oel-Vpk 02s - Part A - Certificate Of Eligibility
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1Florida Office of Early Learning
Form OEL-VPK 02S, Part A (June 2014)-Rule 6M-8.500, Florida Administrative Code. For assistance, call Office of Early Learning at 1-866-357-3239.
STATE OF FLORIDA
VOLUNTARY PREKINDERGARTEN EDUCATION PROGRAM
SPECIALIZED INSTRUCTIONAL SERVICES
CERTIFICATE OF
ELIGIBILITY.
I. 1.EARLY LEARNING COALITION CONTACT INFORMATION. (Completed by early learning
coalition).
Type or print in black or blue
ink.
1. Coalition Name:
2. Address:
3. Telephone Number:
4. Fax Number:
5. Point of Contact (Optional):
6. Email Address (Optional):
7. Website to access Form OEL-VPK 20S (Specialized Instructional Services Provider Agreement):
(Issued by Early Learning
Coalition).
II. 2.CERTIFICATE OF CHILD
ELIGIBILITY.
8. Student’s Full Name:
9. Student Date of Birth:
10. Student ID, if available:
11. VPK Program Year:
12. Certificate Number:
13. Certificate Issue Date:
14. Enrollment:
New Enrollment.
Re-enrollment.
Good Cause Exemption.
III.
3.
ADMISSION BY SPECIALIZED INSTRUCTIONAL SERVICES (SIS) PROVIDER . (Jointly Prepared by Provider AND Parent) .
Provider must visit the website listed in Item 7 to obtain a copy of the VPK Specialized Instructional Services Program
Provider Agreemen (SIS Agreement). An SIS Agreement must be signed by an authorized representative and returned
to the Early Learning Coalition (Item 1) before serving children through the SIS program. Provider is only required to
sign one SIS Agreement per program year.
15. Name of SIS Provider:
16. Daytime Telephone:
17. Fax:
Type of
2
18. Address of SIS Provider:
1
20. Employer Identification Number
:
19.
Service Provided
:
21. Signature of SIS Provider Representative:
22. Date:
23. Parent Signature:
24. Date:
(Submitted by SIS
Provider).
IV.
4.
ENROLLMENT SUBMISSION AND
CONFIRMATION.
Upon completion of Section III above, the SIS Provider must contact the early learning coalition identified in Section I to obtain a
confirmation number. The confirmation number authorizes the early learning coalition to make payments for the VPK Specialized
Instructional Services Program. The coalition will issue a confirmation number that allows payments to be made on behalf of the
student and confirms that the parent has chosen the provider as the student’s SIS Provider.
25. Confirmation Number:
IS THE CONFIRMATION NUMBER.
Footnote
1
Type of Service. Enter one of the following codes:
ABA (Applied Behavior Analysis).
OT (Occupational Therapy).
LS (Listening and Spoken Language Specialist).
SP (Speech-language Pathology).
PT (Physical therapy).
Other (Other, consistent with the student’s IEP).
Footnote
2
PRIVACY ACT STATEMENT – Your employer identification number (EIN) or social security number (SSN) is requested in
accordance with ss. 119.071(5)(a)2. and 119.092, F.S., for use in the records and data systems of the Office of Early Learning and
early learning coalitions. Submission of your EIN or SSN on this form is mandatory. Your EIN or SSN will be used for processing
payments to you as a VPK provider or school, for reporting those payments for federal tax purposes and for routine identification of
your provider or school.
Form OEL-VPK 02S, Part A (June 2014)
Rule 6M-8.500, Florida Administrative Code
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