Sending Out Support - SOS
Request for Support
The Early Learning Coalition of Osceola County is available to provide on-site technical assistance for providers who serve children with
learning difficulties. These services are available whether or not a child has been diagnosed with a special need.
Instructions: If you have a concern about a child, and would like a professional recommendation and support, complete this
Request for Support, along with the attached Readiness Skills checklist and the Vision Concerns Checklist.
Submit to:
The Early Learning Coalition of Osceola County
1631 E. Vine St. Suite E
Kissimmee, FL 34744
407-705-1926 fax 407-933-5012
Have you included?
 SOS Request for Support
 Parent’s Signature on Request for Support
Request for SOS Services:
Date of Request: ___________________________
Name of Child Care Center: ____________________________________________________________________________
Address: ___________________________________________________________________________________________
(Street # and Name)
(City)
(Zip)
Teacher: __________________________________________ Daytime Phone: ___________________________________
Director: __________________________________________ Email: ___________________________________________
Child’s Name: _____________________________________Age: _______________ Birth-date:_____________________
Parent/Guardian:_________________________________________ Daytime Phone: _____________________________
Address: ___________________________________________________________________________________________
(Street # and Name)
(City)
(Zip)
Diagnosis (if known): _________________________________________________________________________________
Type of Services Requested:




Community Inclusion Services
Speech Language Services
Occupational Services
Staff Training Class
 Physical Therapy Services
 Parent Training Class
 Other _______________________________________
Child’s Strengths:
 Social Skills with Children/Adults  Affectionate
Shares/ Patient
Cooperative/Plays Well
 Follows instructions
 Asks to do new things
Reacts Positive to External Praise  Expresses emotions appropriately
Concerns:
Lacks Focus
Needs Constant Redirection
Impulse Control
 Overly Aggressive/Physical
 Exhibits Fears & Anxiety
Isolation
 Using Obscene Language or Gestures
Developmental (Including Communication, Fine/Gross Motor and Cognitive
Please check any of the following that apply:
 School Readiness Funded
 Voluntary Prekindergarten Student
Permission Statement: As the parent/guardian of the child named above, I give permission for the Early Learning Coalition of
Osceola County Inclusion Specialist to complete an observation on my child to determine eligibility for services.
_________________________________________________________
Parent’s Signature
______________________________________
Date
Sponsored by The Early Learning Coalition of Osceola County, and Florida’s Office of Early Learning