Please fill out the online SEEDS application as thoroughly as possible. At the end, you will be given a chance to review the form before final submission. Please be accurate as possible due the fact that inaccurate information may delay the processing of your application. Your e-signature will constitute consent for contact from a representative of the SEEDS team.

Supporting and Empowering Educational and Developmental Services (SEEDS) APPLICATION
School staff: Please complete questions 1-5. Please forward the Hillsborough County Public School Consent Form, a copy of the most recent Report Card, and any available IEP's, Psychological Evaluations, or other relevant information along with a copy of this SEEDS Application to your SEEDS office or Team Member.

* Required Fields
1. Identifying Information (Child)
Name:
(*First Middle *Last)
Date of Birth:* SS#: --
Gender:* Male  Female Student ID:

2. Contact Information (Parent/Caregiver)
Name:*(First, Last) City:*
Street Address:* State:*
Zip:*
Home Phone:*-- Work Phone: -- Ext:
Alternate Phone: -- Language Preference:*
Gender:* Male  Female Email Address:

3. Contact Information (Emergency Contact - Non-Household Member)
Name: (First, Last) Relationship to Child:
Home Phone:-- Work Phone:-- Ext:
Alternate Phone:--

4. Application Source & School/Childcare Information (if applicable)
Name:
(First, Last)
 
Title: Program Name:
Teacher Name: Grade Level:*
Agency/School:*
(if none write N/A)
City:
   State:
Zip:
Work Phone: -- Ext:

Briefly describe reason for application and concerns:*

5. Current Educational Placement*
N/A - Child not enrolled in daycare, preschool or school.
Daycare Center, Preschool, Family Childcare
Regular Education
Hospital/Home-Bound Instruction
Home-Schooled
Other
ESE Services Type:   If Other:

Please forward the following to your SEEDS office or staff:
  • Hillsborough County Public School Consent Form
  • A copy of the most recent Report Card,
  • Any available IEP's, Psychological Evaluations, or other relevant information

APPLICATION ACKNOWLEDGEMENT AND SUBMISSION

I affirm that the facts set forth in this application are, to the best of my knowledge, true and complete. I give permission to The Children's Home, Inc. and its representatives to contact the parent/caregiver of the child as entered in this SEEDS application in connection with my desire to seek services with the Supporting and Empowering Educational and Developmental Services (SEEDS) program. I acknowledge that if this application is being completed by someone other than the parent/caregiver of this child, that I have spoken with and received permission from the caregiver to submit this application on their behalf.

BY SUBMITTING THIS APPLICATION, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE PROVISIONS STATED ABOVE.

  *I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE PROVISIONS STATED ABOVE:

DO NOT E-SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT. By my eSignature below, I certify that I have read, fully understand and accept all terms of the foregoing statement. Please signify your acceptance by entering the information requested in the fields below.

*If completed by the parent/caregiver, please enter your full name:
*If completed on behalf of the parent/caregiver, please enter your full name:
*Please enter the parent/caregiver unique identifier, to include the first four digits (0000 if none) of your social security number followed by your zip code: