SES Form

 

Enrollment Form

Request for Supplemental Educational Services (SES)

 

Directions:

Complete all of the information below including listing your SES provider/tutoring choices.

A Parent/Guardian must sign this form.  Services will not be approved or provided without a valid signature.

Return this form to your child’s school.  Deadline is February 22, 2012.

 

______________    ______________    ___/__/___     _________   _______   ______

Student’s Last Name Student’s First Name Date of Birth Current Grade Student ID    Gender

 

____________________ _____________________________

SES Eligible School Classroom/Homeroom Teacher

 

 

Parent/Guardian Information: ____________________________ ___________________________________

Last Name First Name

 

__________________________________________________________________________________________

Home Address

 

Phone 1: ____________________ Type: ______________________

 

Phone 2: ____________________ Type: ______________________

 

Email: ___________________________________________________

 

 

PLEASE COMPLETE THE FOLLOWING SECTION:

 

Supplemental Educational Services Selection - Please list your first, second, and third choice of SES provider below.

1^st Choice: _____________________________________________________

2^nd Choice: ____________________________________________________

3^rd Choice: _____________________________________________________

 

 

Your first choice of SES provider will be honored as much as possible, however, please understand that a provider may not be available in every area of the district.  If your first choice is not available to provide services your child will be assigned to your 2^nd or 3^rd choice.

 

By signing this form I give permission for the release of my child’s education records, including Individualized Education Plan or 504 Plan to the provider selected to provide tutoring for my child.  This information is for educational purposes only.  I understand that this provider has agreed to maintain the confidentiality of my child’s educational records.

 

________________________________ ________________

Parent/Guardian Signature Date

 

 

_______________________________________

Printed Name of Parent/Guardian