Fillable Field Trip Or Excursion Parental Information printable pdf download

STATE OF FLORIDA

VOLUNTARY PREKINDERGARTEN EDUCATION PROGRAM

Good Cause Exemption Application

Parents: Please complete this form and submit it with the required supporting documentation to the local early learning coalition. If the coalition

approves this application, the coalition will return a copy of this form to you for delivery to your new VPK provider. You will also be notified if this form

is not approved for a good cause exemption.

Has your child ever previously been reenrolled for good cause or due to extreme hardship in the VPK program?

No – If you checked “No,” you may not submit this form. Please complete the Reenrollment Application, Form OEL-VPK 05 (dated 04-09-10)

and submit that form directly to the Early Learning Coalition.

Yes – If you checked “Yes,” continue to item 1. Upon completion, please submit this form directly to the Early Learning Coalition.

1. Full Name of Student (first, middle, last, Jr./Sr./III):

2. Student’s Date of Birth:

3. Name and Address of the Previous VPK Provider:

4. Name and Address of the New VPK Provider:

5. Mark the Box Indicating the Reason(s) for Student’s Good Cause Exemption from the VPK Program’s One-Time Reenrollment Limitation:

A change in the student’s residence that extended the student’s round-trip travel time by 60 minutes or more, to and from the VPK provider, as

supported by third-party documentation showing the change (e.g. rental agreement or receipt from rent payment, mortgage, or utility records); or

resulted in a temporary stay in a homeless shelter or transitional housing entity, as supported by third-party documentation (e.g. letter from a homeless

shelter or transitional housing entity); or resulted in a temporary stay in, or move out of a domestic violence shelter or transitional housing entity, as

supported by third-party documentation (e.g. letter from a domestic violence shelter or transitional housing entity or court-issued domestic violence

injunction)

A change in a parent’s employment that extended the parent’s or guardian’s round-trip travel time by 60 minutes or more, to and from the VPK

provider, supported by an employment letter from the new employer indicating start date or an employment letter from an existing employer showing

such a change in employment location

A change in a migrant (as defined in 6M-4.100(16), F.A.C.) parent’s employment, supported by an employment letter from the new employer indicating

start date or an employment letter from an existing employer showing a change in employment location

A temporary or permanent change in parent custody or guardianship, supported by legal documentation (e.g., court order or official documentation on

DCF letterhead)

Student’s parent(s) is active duty military and deployed (i.e., power of attorney and proof of current military enlistment)

The termination of the student’s VPK class, into which the student was reenrolled, before the student has been funded for 70 percent of the class

instructional hours in the program, as confirmed by the coalition on official letterhead or by DCF on official letterhead or from a CCIS screen print

The provider’s inability to meet the student’s educational needs due to the student’s learning or developmental disability as documented by a federal,

state, or local governmental official

The VPK student’s initial enrollment was the result of a termination of the student’s VPK class before the student had been funded for 70 percent of the

class instructional hours in the program, as confirmed by the coalition on official letterhead or by DCF on official letterhead or from a CCIS screen print

A provider is found to have committed a Class I Violation as defined in 65C-22.010 or 65C-20.012, F.A.C. (as applicable to the provider type), as

documented by DCF on official letterhead or from a CCIS screen print

A serious injury to the child that occurred at the provider and which required the provider to contact medical services, as documented on the DCF

Accident/Incident Report for licensed providers or on official provider letterhead for license-exempt providers

The student was dismissed from a VPK provider for issues that prevented the provider from meeting the student’s educational needs, as substantiated

by the dismissing provider on official letterhead

Informed Parental Consent

By signing this form, you certify that you have been informed of the number of remaining VPK instructional hours your student is eligible to receive and that

you have been informed of the number of instructional hours remaining in the new VPK class you have selected. You certify that you make this choice freely,

understanding that your student:

•

May not receive all instructional hours (540 for school-year or 300 for summer) if the number of instructional hours remaining in the new VPK class

you selected is fewer than the number of remaining hours of instruction the student is eligible to receive.

•

May not have enough remaining hours of eligibility to attend all instructional hours offered by the provider in the class you select.

May not be granted another good cause exemption in the VPK program.

•

6. Full Name of Parent or Guardian (first, middle, last, Jr./Sr./III):

7. Phone Number:

8. Address of Parent or Guardian:

9. Email Address (if available):

10. Signature of Parent or Guardian:

11. Date Signed:

OFFICIAL USE ONLY – Coalition staff must complete all boxes. If VPK student is eligible for a good cause exemption, return copy of completed form to parent.

Student’s Last Day Attended with Previous

Student’s Total Remaining VPK Instructional Hours:

Class ID of Previous

Class ID of New Provider:

Provider:

New Provider’s Total Remaining VPK Instructional

Student Has Substantially Completed the

Student Has Previously Reenrolled For Good Cause or

Hours:

VPK Program:

Yes

Extreme Hardship: