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Permission to Succeed Education Center

PTSEC Enrollment Application

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Enrollment Application

Complete the application below to begin your child’s enrollment at Permission To Succeed Education Center.

Start Application 954.369.4276

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Permission to Succeed Education Center enrollment application and student information packet.

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Permission to Succeed Education Center (PTSEC)
Enrollment Application and Student Information Packet
Submission of this application does not guarantee admission. PTSEC reviews academic history, learning profile, behavior and safety needs, attendance, available records, and the school's ability to provide an appropriate placement. Final enrollment is complete only after written acceptance, receipt of required records, completion of all enrollment agreements, and satisfaction of financial or scholarship agreements. Please use the student's legal name exactly as it appears on official records.
Application Type*
- New Student
- Returning Student
- Midyear Entry
School Year*
- 2026-27
Application Date*
Date Format: MM slash DD slash YYYY
Requested Start Date
Date Format: MM slash DD slash YYYY
Referred By
Name or source
A. Application Submission Checklist
Submit the following items with this application, as applicable. Do not submit original custody orders or irreplaceable records; PTSEC may request additional documentation after review.
Documents included or to be provided
1. Completed and signed applicationThis online form. Signatures are collected in Section 11.
2. Application or registration fee, if required
3. Certified birth certificate or other proof of age
4. Parent or legal guardian photo identification
5. Proof of current address or Florida residencyFor example, a utility bill, lease, or mortgage statement.
6. School-entry health examination completed within the required periodFlorida Form DH 3040: Download form (PDF) · Spanish (PDF) · Instructions (PDF)
7. Florida Certification of Immunization, Form DH 680Issued only by your child's Florida physician, APRN, or county health department (not available as a download).
8. Religious exemption Form DH 681, or documented medical exemptionDH 681 is issued only by your county health department. Exemption information
9. Most recent report card or progress report
10. Official transcript and credit history for grades 9-12
11. Attendance and discipline records
12. Recent standardized or diagnostic test results
13. Current IEP, 504 Plan, EP, service plan, or accommodation plan
14. Psychological, neuropsychological, speech, OT, PT, ABA, or other evaluations
15. Behavior intervention, safety, crisis, or elopement plan
16. Custody, guardianship, restraining, or pick-up restriction documentsCopies only. Do not submit originals.
17. Scholarship Award ID (Step Up recipients only)
18. Any other document requested by PTSEC Admissions
Florida Health Record Reminder: Students making their initial entry into a Florida school must provide a school-entry health examination completed within one year before enrollment, plus immunization documentation or a valid exemption.
Upload Your Documents
Upload each document in its own field below. Skip any that do not apply or that you will provide later. Accepted: PDF, JPG, PNG, HEIC, Word. Up to 3 files per item (for multi-page documents).
Fee payment receipt
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Birth certificate or proof of age
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Parent or legal guardian photo ID
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Proof of address or Florida residency
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
School-entry health examination (DH 3040)
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Florida Certification of Immunization (DH 680)
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Immunization exemption (DH 681 or medical exemption)
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Most recent report card or progress report
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Official transcript and credit history (grades 9-12)
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Attendance and discipline records
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Standardized or diagnostic test results
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
IEP, 504 Plan, EP, service plan, or accommodation plan
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Psychological, speech, OT, PT, ABA, or other evaluations
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Behavior intervention, safety, crisis, or elopement plan
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Custody, guardianship, restraining, or pick-up restriction documents
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Scholarship award letter (Step Up recipients only)
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Other documents requested by PTSEC Admissions
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, heic, doc, docx.
Any additional documents PTSEC Admissions has requested. Up to 5 files.

1. Student Information and Program Selection
Legal Last Name*
Legal First Name*
Middle Name
Suffix
Preferred Name
Name used at school
Date of Birth*
Date Format: MM slash DD slash YYYY
Age
Birthplace
City, State, Country
Sex as Listed on Birth Record
- Female
- Male
Race
For student records
Ethnicity
Optional
Primary Language
Home Language
Student Email
Student Mobile
RBT Needed*
Note: We do not provide Registered Behavior Technician (RBT) services. However, please let us know if your child currently receives or requires RBT support so we can better understand their needs and determine whether our program is a suitable fit.
- Yes
- No
Grade Applying For*
- Kindergarten
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
Requested PTSEC Location or Program
- Fort Lauderdale K-12 day school
- Fort Pierce homeschool support program
- Lauderhill enrichment or homeschool support center
Requested Instructional Setting or Services
- Full-time private school enrollment
- Part-time private school enrollment
- Hybrid private school enrollment
- Homeschool academic support
- Credit recovery or graduation planning
- Other
Other instructional setting (if selected above)
Student Home Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address (if different)
Same as previous
Street Address Address Line 2 City State ZIP Code
Student Currently Lives With
- Both parents
- Mother
- Father
- Legal guardian
- Grandparent
- Foster placement
- Other
Other living arrangement (if selected above)
Sibling(s) Applying or Enrolled at PTSEC
Name and grade
Previous PTSEC Enrollment
Year and grade, if applicable
Anticipated Graduation Year
For grades 9-12
Reason for Applying to PTSEC
Describe the student's current educational needs and what the family is seeking in a school placement.

2. Parent, Guardian, Household, and Custody Information
PTSEC must be able to identify the persons who have legal educational decision-making authority and access rights.
Parent or Guardian 1
Parent/Guardian 1 Full Legal Name*
Parent/Guardian 1 Relationship to Student
Parent/Guardian 1 Home Address (if different from student)
Street Address Address Line 2 City State ZIP Code
Parent/Guardian 1 Mobile Phone*
Parent/Guardian 1 Alternate Phone
Parent/Guardian 1 Email Address*
Parent/Guardian 1 Employer or Organization
Optional
Parent/Guardian 1 Work Phone
Parent/Guardian 1 Preferred Contact Method
- Call
- Text
- Email
Parent or Guardian 2 (if applicable)
Parent/Guardian 2 Full Legal Name
Parent/Guardian 2 Relationship to Student
Parent/Guardian 2 Home Address (if different from student)
Street Address Address Line 2 City State ZIP Code
Parent/Guardian 2 Mobile Phone
Parent/Guardian 2 Alternate Phone
Parent/Guardian 2 Email Address
Parent/Guardian 2 Employer or Organization
Optional
Parent/Guardian 2 Work Phone
Parent/Guardian 2 Preferred Contact Method
- Call
- Text
- Email
Person Financially Responsible
Financially Responsible Person Full Legal Name
Financially Responsible Relationship
Financially Responsible Email
Billing Address
Street Address Address Line 2 City State ZIP Code
Billing Phone
Legal Status and Decision-Making Authority
- Parents share legal custody
- Parent or Guardian 1 has sole legal custody
- Parent or Guardian 2 has sole legal custody
- Court-appointed guardian
- Foster or agency placement
- Custody or access is disputed
- No court order exists
- Other
Custody, Guardianship, and Access Restrictions
Explain any limits on educational decisions, records access, visitation, contact, or student release. Attach current legal documentation.
Person Prohibited from Contact or Pick-up
Full name
Prohibited Person Relationship
Order Expiration Date
Date Format: MM slash DD slash YYYY

If applicable
Court or Agency Contact
Name and phone, if applicable
Case or Reference Number
Optional

3. Educational History and School Records
Current or Most Recent School
Current School Type
- Public
- Private
- Home Education
Current School Address
Street Address Address Line 2 City State ZIP Code
Current School Phone
Current School Records Email or Fax
Dates Attended (current school)
Current Grade
Last Grade Completed
Date Last Attended
Date Format: MM slash DD slash YYYY
Reason for Leaving or Seeking a New Placement
- Relocation
- Academic needs
- Learning support needs
- School climate or safety
- Attendance concerns
- Behavioral concerns
- Discipline action
- Program no longer appropriate
- Family choice
- Other
Other reason for leaving (if selected above)
Previous School 1
Name, city, state; grades and dates attended; reason for leaving
Previous School 2
Name, city, state; grades and dates attended; reason for leaving
Previous School 3
Name, city, state; grades and dates attended; reason for leaving
Academic and Attendance History (check all that apply)
- Repeated a grade
- Skipped or accelerated a grade
- Chronic absences or tardiness
- Home education during any prior year
- Online or virtual school coursework
- Credit recovery
- Failed one or more core courses
- High school credits earned before grade 9
- On track for graduation
- Graduation progress is uncertain
- English learner services
- Gifted services
Discipline and School Placement History (check all that apply)
- No significant disciplinary history
- In-school suspension
- Out-of-school suspension
- Expulsion or recommended expulsion
- Alternative school placement
- Involuntary withdrawal or non-renewal
- Threat assessment or safety review
- Law enforcement involvement at school
- Bullying concern as target
- Bullying concern as alleged aggressor
A 'yes' response does not automatically disqualify an applicant. PTSEC requires enough detail to make an informed safety and placement decision.
Academic, Attendance, or Discipline Explanation
Provide dates, context, outcomes, current supports, and any records PTSEC should review.

4. Learning Profile, Exceptional Student Education, and Support Needs
Complete this section fully. Accurate disclosure helps PTSEC evaluate program fit, staffing, accommodations, and safety supports.
Current or Prior Plans and Services
- Individualized Education Program (IEP)
- Section 504 Plan
- Educational Plan (EP) for gifted services
- Private school service plan
- Behavior Intervention Plan (BIP)
- Functional Behavior Assessment (FBA)
- Safety or crisis plan
- No formal plan
- Plan is being developed or reevaluated
- Other
Diagnoses, Eligibility Areas, or Documented Learning Needs
- Attention-Deficit/Hyperactivity Disorder (ADHD)
- Autism Spectrum Disorder (ASD)
- Specific learning disability
- Dyslexia or reading disorder
- Dysgraphia or written expression difficulty
- Dyscalculia or math disability
- Speech or language impairment
- Processing speed or working memory difficulty
- Executive functioning difficulty
- Anxiety or school avoidance
- Depression or mood-related concern
- Intellectual disability
- Sensory processing needs
- Physical or medical disability
- Gifted or advanced learning needs
- No known diagnosis or formal eligibility
- Other
Current or Prior Outside Services
- Applied Behavior Analysis (ABA)
- Registered Behavior Technician (RBT)
- Speech-language therapy
- Occupational therapy
- Physical therapy
- Mental health counseling
- Psychiatric services
- Tutoring or academic therapy
- Social skills group
- Case management
- None
- Other
Describe the Student's Learning Profile
Include strengths, learning preferences, challenges, effective strategies, current instructional level, and conditions that improve performance.

5. Behavior, Regulation, Safety, and Student Success Planning
This information is requested for safety planning and program fit. Disclosure alone does not automatically disqualify a student. Attach current safety or crisis plans when applicable.
Within the last 24 months, has the student experienced or displayed any of the following?
- Elopement, wandering, or leaving supervision
- Physical aggression toward others
- Threats of harm toward others
- Property destruction
- Self-injury
- Suicidal statements, ideation, or attempts
- Severe emotional escalation or shutdown
- Restraint, seclusion, or crisis intervention
- Psychiatric hospitalization or mobile crisis response
- School refusal or prolonged avoidance
- Substance use concern
- Sexually unsafe or boundary-related behavior
- Fire-setting or weapon-related concern
- Law enforcement or juvenile justice involvement
- None of the above
Safety-Related Details and Current Plan
For each checked item, provide approximate dates, frequency, triggers, level of supervision required, successful responses, current providers, and whether the concern is active.
Student Strengths, Interests, and Motivators
What does the student enjoy? What builds confidence, engagement, trust, and persistence?
Parent or Guardian Goals for This School Year
Identify the three most important academic, behavioral, social, executive functioning, or graduation outcomes.

6. Health, Medical, Allergy, and Emergency Information
Complete all items. Medication administration and individualized health plans require separate school forms.
Primary Care Provider
Name and practice
Primary Care Provider Phone
Specialist or Behavioral Health Provider
If relevant
Specialist Phone
Preferred Hospital
Optional
Health Insurance
Carrier and member ID, optional
Allergies and Required Response
List food, medication, insect, environmental, or latex allergies. State reaction, severity, and required response, including epinephrine or emergency medication.
Emergency Medication
Epinephrine, inhaler, seizure rescue, etc.
Emergency Medication Expiration Date
Date Format: MM slash DD slash YYYY
Emergency Medication Plan Attached*
- Yes
- No
Emergency Medication Plan*
Health Information School Staff Need to Know
Include activity restrictions, dietary needs, toileting support, sleep concerns, recent surgery or injury, mental health considerations, or other care instructions.
Emergency Contacts
Emergency Contact 1 - Name, Relationship, Primary Phone, Alternate Phone*
Emergency Contact 2 - Name, Relationship, Primary Phone, Alternate Phone
Emergency Contact 3 - Name, Relationship, Primary Phone, Alternate Phone

7. Transportation, Arrival, Dismissal, and Authorized Release
Primary Daily Arrival Method
- Parent or guardian vehicle
- Authorized adult vehicle
- Student drives
- Public transportation
- Rideshare with separate written authorization
- Walk or bicycle with written authorization
- Other
Primary Daily Dismissal Method
- Parent or guardian pick-up
- Authorized adult pick-up
- Student drives
- School transportation
- Public transportation
- Rideshare with separate written authorization
- Independent release or walk with written authorization
- Aftercare
- Other
Authorized Pick-up Person 1
Full legal name, relationship, phone
Authorized Pick-up Person 2
Full legal name, relationship, phone
Authorized Pick-up Person 3
Full legal name, relationship, phone
Authorized Pick-up Person 4
Full legal name, relationship, phone
Persons Not Authorized for Pick-up or Contact
List full name, relationship, and legal basis for restriction. Attach the current order or documentation.
Independent Release Authorization for Eligible Students
- Not authorized
- Authorized to walk or bicycle home
- Authorized to use public transportation
- Authorized to leave independently at dismissal
- Authorized to drive self
- Authorized to transport sibling(s)
Sibling(s) authorized to transport (if selected above)
Student Driver License Number
If applicable
Vehicle Make and Model
Vehicle Color
License Plate
Usual Dismissal Time
Aftercare Needed
- Yes
- No
Days of Week (aftercare)
Special Arrival, Dismissal, or Supervision Instructions
Include split-household schedules, alternating days, early release restrictions, transportation provider information, or safety concerns.

8. Scholarship, Tuition, and Financial Information
Expected Funding Source
- Step Up for Students
- AAA Scholarship Foundations
Expected Funding Type
- Florida Tax Credit Scholarship (FTC)
- Family Empowerment Scholarship for Educational Options (FES-EO)
- Family Empowerment Scholarship for Students with Unique Abilities (FES-UA)
- Personalized Education Program Scholarship (PEP)
- Private pay
- Other scholarship or funding source
- Funding source not yet determined
Other scholarship or funding source (if selected above)
Student ID (Previously Known as Award ID)
If known
Financial Acknowledgments (please check each to acknowledge)*
- I understand a scholarship may not cover full tuition and fees.
- I accept responsibility for balances not paid by a scholarship or other funding source.
- I will complete parent approvals, endorsements, or confirmations in the applicable scholarship portal by required deadlines.
- I will notify PTSEC immediately of any scholarship change, denial, suspension, or transfer.
- I understand that tuition, fees, refunds, withdrawals, and payment obligations are governed by a separate enrollment or financial agreement.
- I understand that acceptance into PTSEC is separate from scholarship eligibility or funding approval.
Responsible Party Full Legal Name
Responsible Party Relationship to Student
Billing Email
Billing Phone (financial)
Billing Address (financial)
Street Address Address Line 2 City State ZIP Code

9. Communication Preferences and Family Information
Preferred School Communication Channels
- Email
- Text message
- Phone call
- ClassDojo or school messaging platform
- Printed notice
- Other
Language Preference for School Communication
- English
- Spanish
- Haitian Creole
- Interpreter requested for meetings
- Other
Primary Communication Email
Primary Mobile Number
Secondary Communication Email
Secondary Mobile Number
Family Information That May Affect Student Success
Share significant transitions, housing or transportation concerns, military deployment, recent loss, family schedule, or other information the school should handle sensitively.

10. Permissions and Authorizations
Check each selection to grant permission. PTSEC should follow the most restrictive selection when instructions conflict.
Authorizations (check each to grant)*
- Emergency response authorization. If I cannot be reached, I authorize PTSEC to contact emergency services, provide reasonable first aid within staff training, and release the student to emergency medical personnel. I understand that I am responsible for medical costs.
- Records authorization. I authorize PTSEC to request, receive, review, and maintain educational, attendance, disciplinary, health, evaluation, and support records reasonably related to admissions, placement, safety, and educational planning.
- Electronic communication consent. I consent to school-related calls, emails, portal messages, and text messages at the contact information provided. Message and data rates may apply.
- Technology and digital learning acknowledgment. I authorize the student to use school-approved devices, internet access, learning platforms, educational software, and school accounts subject to PTSEC's Acceptable Use Policy and supervision practices.
- Assessment authorization. I authorize PTSEC to administer admissions, placement, diagnostic, progress-monitoring, standardized, and curriculum-based assessments reasonably needed for educational planning and scholarship compliance.
Media and Publicity Choices
Choose each permission separately. Media permission may be changed prospectively by written notice.
Internal School Use (classroom projects, yearbook, portfolio, closed family events, internal displays)
- YES, internal school use permitted
- NO internal school use beyond required student identification and educational records
External School Use (website, social media, brochures, presentations, news coverage, promotional materials)
- YES, external school use permitted
- NO external school publicity or promotional use
Use of Student's First Name with Approved Media
- Student's first name may be used with approved media
- Do not use the student's name with approved media
Records Release to Third Parties - PTSEC may communicate with the following providers
- Current or prior school
- Evaluator or therapist listed in this application
- ABA or RBT provider approved for school coordination
- Public school district for records or services
- No additional provider communication without a separate written release
Limits on Permissions or Additional Instructions
Describe any restrictions, expiration dates, or specific persons or organizations covered by your authorization.

11. Parent or Guardian Attestations and Signatures
By checking below, each undersigned parent or legal guardian affirms the following.
Attestations (check each to affirm)*
- The information provided in this application and all attachments is complete and accurate to the best of my knowledge. I have not intentionally omitted academic, behavioral, health, safety, custody, disciplinary, or support information that could materially affect admissions, placement, or student safety.
- I will promptly provide updated information when the student's address, custody status, health condition, medication, provider, scholarship, transportation plan, or emergency contact information changes.
- I authorize PTSEC to verify information provided and to contact prior schools, listed professionals, scholarship organizations, and references as reasonably needed for admissions and educational planning.
- I understand PTSEC may require an interview, records review, observation, assessment, trial period, conditional acceptance, support plan, or additional documentation before or after an admissions decision.
- I understand that academic grade placement and course placement may be based on PTSEC's review and assessment rather than solely on age or the grade previously reported by another program.
- I understand PTSEC is an educational institution and not a hospital, psychiatric facility, crisis stabilization unit, or substitute for required medical or therapeutic care. I will maintain outside services when needed for the student's safe participation.
- I understand that enrollment may be reconsidered if material information was withheld, required records are not provided, the student's needs materially exceed available services, safety conditions cannot be maintained, or the family does not comply with applicable agreements and policies.
- I understand this application is not the enrollment contract. If accepted, I must sign PTSEC's enrollment, tuition, handbook, technology, health, and other required agreements before the student attends.
- I acknowledge PTSEC's expectation of regular attendance, punctuality, respectful conduct, family communication, and cooperation with academic and student support plans.
- I have had an opportunity to ask questions and authorize PTSEC to evaluate this application for admission.
Signatures
Parent or Legal Guardian 1 - Printed Name*
Parent or Legal Guardian 1 - Signature*
Parent or Legal Guardian 1 - Date*
Date Format: MM slash DD slash YYYY
Parent or Legal Guardian 2 - Printed Name
Parent or Legal Guardian 2 - Signature
Parent or Legal Guardian 2 - Date
Date Format: MM slash DD slash YYYY
Nondiscrimination: PTSEC administers admissions without discrimination based on race, color, or national origin, consistent with applicable law. Each applicant is reviewed individually.
Application Completed By
Name and relationship to student
Date Completed
Date Format: MM slash DD slash YYYY

Questions? Call us at 954.369.4276 or our admin office at 954.397.2793.

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