2025-2026 ASP INTEREST FORM

CITY OF HALLANDALE BEACH HUMAN SERVICES DEPARTMENT 2025-2026 ASP INTEREST LINK

Quick Interest Form One Time Fee $200 per child for Hallandale Beach Residents - $400 per child for Non- Residents Cash Only!
Student Name*

First NameLast Name
Student name
First- Middle- Last name
Date of birth*

MonthDayYear
Date
Student's age*
Last 4 numbers of Student's Social#*
*If student has no social enter year of birth as last 4 SSN
Race/Ethnicity*
Gender*
Name of current school*
Student Number*
10 digit number begins with 06
RACE/ETHNICITY
Current Grade 2025-2026 school year*
Home Address *
City*
Zip code*
Number of people living in the home*
# of people living in home
Annual Household Income*
Gross income for all working adults 18+ i.e. Gross Monthly Income $1000 x 12 Months = $12,000 + $506 Food Stamps x 12 Months = $6,072 + $904 Social Security Disability x 12 Months = $10,848
Passcode*
4 digit code -for dismissal
Mother's name*
PHONE (Mobile)*

Area CodePhone Number
Mother's place of employment
Mother phone (Work)

Area CodePhone Number
SS#
Father name
Father phone (Mobile)

Area CodePhone Number
Father's place of employment
Father phone (work)

Area CodePhone Number
Father phone (Work)

Area CodePhone Number
SS#
HOURS
HOURS
MOBILE PHONE

Area CodePhone Number
PHONE

Area CodePhone Number
Parent's Email*
example@example.com
FATHER'S E MAIL
example@example.com
RELATIONSHIP
Emergency Contact *
Please provide full name and relationship to the student
Emergency Contact Phone #*
In the following format - area code first and seven digits of number follow separated by a hyphen ex. (954) 333-1111
Does this student have an Individualized Education Plan (IEP)?*
Does your child have any special needs, a disability, and/or or require special accommodations?*
Please provide any information necessary for our staff to provide excellent services to your child
Does your student have a Registered Behavioral Therapist (RBT)?*
Does your child have any allergies? *
Please list allergies below (if applicable)*
If you answered no to the question above, place N/A in the field above
Does your child take medication?*
If you answered yes to medication. Please list the name of the medication, dosage , and frequency taken below. ** If your child does not take any medication put N/A in the box below.***
Are you registering another student?*
Name of other student (s) if applicable?
Emergency Contact Phone #

Area CodePhone Number
II. LIST INDIVIDUAL(S) AUTHORIZED TO PICK UP CHILD:

NAME

PHONE

AGE

RELATIONSHIP
Appointment/Cita*
PARENT SIGNATURE*

Clear
DATE*

MonthDayYear
Date
Social Worker verified a copy of student's Birth Certificate is in the file. Social Worker verified a copy of student's Social Security Card is in the file. Notes/Special Instructions:
HSD-YS-13 EFF.05/07 - Revised 4/30/08

C:UserskkshawDesktopHHSD-YS-23-SPRING BREAK QUICK REGISTRATION FORM.doc
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CITY OF HALLANDALE BEACH HUMAN SERVICES DEPARTMENT 2025-2026 ASP INTEREST LINK