Parenting Education Program Inquiry for Services (Miami)


Please fill out the form below, and someone from our office will be in touch once your application has been reviewed.  If you prefer to download a paper copy and send it back via fax, you can do so by clicking here.


 

Adult Information

Are you a parent, guardian, or primary caregiver?
How many of the children in your care have a disability or condition that is expected to last for a year or more that makes it harder for your child to do things that other children the same age can do?
mm/dd/yyyy
The best number for us to contact you.
Gender
Proficient in English
Languages Spoken
If you selected "Other" please list them here.
Please tell us the language in which you'd like to receive communication.
Ethnicity
Race
Highest Education Level Completed
If you answered "other" please explain.

Child(ren) Information

mm/dd/yyyy
Gender
Social Security Information
Miami-Dade Public School Information
Current School Information
Proficient in English
Does child have health insurance
Does your child have any Special Needs or health concerns?

Second Child

If applicable
mm/dd/yyyy
Gender
Social Security Information
Miami-Dade Public School Information
Current School Information
Proficient in English
Does child have health insurance?
Does your child have any Special Needs or health concerns?
If you are interested in enrolling more than 3 children, please provide first and last names, date of birth, current age and current grade in school in this area.
Council of Accreditation