Suspended Enrollment Request Form - Version 7 - 2024 - Break-In-Service

Sep 16, 2026

Uploaded by Grenda

Suspended enrollment/break-in-service request form for parents or guardians seeking a service break for enrolled children. Requests must be submitted with proof of a zero balance and meet timing rules: at least two weeks and not more than 90 days per calendar year, with provider selection and ELCOC contract space verification when transferring. The form collects parent, child, current and new provider details plus transfer effective date, includes operational notes for submission cutoffs, backdating restrictions, and possible Family Portal signatures.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Parent/Guardian Information

Child(ren) Break-In-Service Information

Provider Transfer Details

Effective Date of Transfer

Important Notes for Parents/Guardians

ELCOC Use Only

SUSPENDED ENROLLMENT/BREAK-IN-SERVICE REQUEST FORM Submit completed form AND proof of a zero balance by fax at 407-588-9262 . Requests made must be for at least for two (2) weeks or more and cannot exceed 90 days in a calendar year. DO NOT USE WHITE OUT ON ANY FORMS! Parent/Guardian Information: Date: / / Parent/Guardian Name: SSN (optional) Address, City, State, Zip: Employer: Phone \# to be reached: Username Email Address: Child(ren) Break-In-Service Information: I would like to request a break-in-service for the following children: Name: Last date attended: / / Return date: / / Name: Last date attended: / / Return date: / / Name: Last date attended: / / Return date: / / Name: Last date attended: / / Return date: / / FROM: CURRENT PROVIDER-NAME & ADDRESS TO: NEW OR CURRENT PROVIDER-NAME & ADDRESS EFFECTIVE DATE OF TRANSFER, IF APPLICABLE: / / PLEASE NOTE: • Break-In-Service request must be completed by parent/guardian receiving School Readiness services with ELCOC and requested three (3) days prior to effective date. • Your zero-balance letter must be submitted with this form; Zero balance must be verified prior to processing request. If zero balance is not confirmed, this request will be voided and you may have to resubmit. • If transferring providers, you must speak to and chose a provider with a valid ELC of Orange County School Readiness contract and verify space available for child(ren) to start attending within two-weeks (2) weeks from effective date of transfer. • Break-In-Service cannot be back-dated; Requests received after 4 pm, weekends or holidays will be assigned the next business day. • An additional signature may be needed electronically in the Family Portal for you and the provider to view & print the certificate. • Failure to notify ELCOC when your child does not attend provider on the scheduled return date will result in a loss of services and you may have to reapply. ELCOC USE ONLY: Contacted Provider Name Provider Staff Name/Title Date/Time Was zero balance verified? □ Yes □ No If no, amount of delinquent balance Effective 7.1.2024

FAQs

What proof is required to submit a suspended enrollment/break-in-service request?

A zero-balance letter must be submitted with the form. Zero balance must be verified prior to processing, or the request is voided and may need resubmission.

What are the time limits for submitting and approving break-in-service requests?

Requests must be made for at least two (2) weeks or more and cannot exceed 90 days in a calendar year. The request must be completed by the parent/guardian and submitted with ELCOC with at least three (3) days prior to the effective date.

Can break-in-service dates be back-dated, and what happens after submission cutoffs?

Break-in-service cannot be back-dated. Requests received after 4 pm, on weekends, or on holidays are assigned to the next business day.

Sep 16, 2026

Uploaded by Grenda