Enrollment Forms Packet (EFP)

Texas Virtual Academy
Enrollment Processing Center
2300 Corporate Park Drive
Ste 200
Herndon, VA 20171
Ph. 877.554.1084
Fx. 877.257.4612
www.k12.com/txva
Enrollment Forms Packet (EFP)
Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to submit documentation in order to
complete this step in the enrollment process. You can fax, scan and email, or mail the required paperwork .
Important Note: Please send copies, do not mail the original documents
Fax (preferred):
1-877-257-4612
Required For?
Required for all
Students
Recommended for
All Students
Recommended for
all rising 10 -11th
Grade Students
Recommended for
student with an IEP
or other Special
Education needs
Recommended for
students that have a
504 plan
Scan and Email:
[email protected]
Mail:
Texas Virtual Academy
2300 Corporate Park Drive
Ste 200
Herndon, VA 20171
Item
Description
Provided by?
Proof of Age
Official Birth Certificate (not the hospital issued certificate)
Provided by you
Proof of Residency
Two forms of Proof of Residency: Current Utility bill showing service address,
Mortgage statement/Rental contract including signature page, recent tax statement
Provided by you
Immunization Card
Current Immunization Record
Provided by you
Home Language
Survey
Complete this form and submit.
Provided in this
packet
Occupational
Survey
Complete this form and submit.
Provided in this
packet
Ethnicity and Race
Questionnaire
Please write your student’s name, as it was entered on the application.
Provided in this
packet
Student Record
Release
By filling out this form, you are giving our school permission to request your
student’s official records from their previous school after the approval process. If
your child was Homeschooled please indicate it on the form, fill out the top portion and sign it.
Provided in this
packet
Affidavit of Student
Residency
Complete this form and submit.
Provided in this
packet
Free and Reduced
Statement
Complete this form and submit (Example page included for instructions on how to
complete this form)
Provided in this
packet
Special Education/
Child Find
Complete this form and submit.
Provided in this
packet
Student Health
History
Complete this form and submit.
Provided in this
packet
At Risk Indicators
Complete this form and submit.
Provided in this
packet
Report Card
The most recent Report Card
Provided by you
Social Security
Card
Please note do not send actual card, please submit a copy
Provided by You
Transcripts
You will need to request an unofficial transcript from your student’s current
school, which will show your student’s academic standing. This is recommended in order to place all 10th through 11th graders. Once your student is
approved, we will receive the official transcript directly from the school.
Provided by you
IEP
A copy of your student’s current IEP (Individualized Education Plan). Because the
Provided by you
IEP expires yearly, please submit the current IEP.
Evaluation Report
The Evaluation Report is valid for 3 years. If you do not have a copy of your
student’s ER, you can request a copy from your student’s current school.
Provided by you
504 Accommodation Plan
A copy of your student’s current 504 Accommodation Plan. Because the 504
expires yearly, please submit the current 504.
Provided by you
Student Enrollment Application
(PLEASE PRINT)
Student’s Name ________________________________________________ Application Date ____ / ____ / ______
Last
First
Middle
Address _______________________________________________________________________________________
City _______________________________________________ State _____________________ ZIP______________
Home Phone ____________________ Cell Phone ____________________ Social Security # ______ - ____ - ______
Gender (circle one):
M F
Date of birth ____ / ____ / ____ Age ______
School District in which student resides: _______________________
School Name
Last grade completed _______
_______________
ISD
*Local school the student is zoned to attend in relation to current residence and current grade level.
Last School Attended:
School Name __________________________ _______ Phone ____________________________________
Address _ ________________________________________________________________________
City __________________________ State ___________________ ZIP ____________________________
Father’s name ___________________________________________________ Living with student? ___________
Employer _____________________________________________________________________________
Address ______________________________________________________________________________
City ________________________________ State ____ Zip _________ Home Phone _______________
Work phone (______) ______ - __________ Cellular phone/Pager/Etc. (______) ______ - _____________
Driver’s License # ____________________ (State) ________ Email_______________________________
Mother’s name __________________________________________________ Living with student? ___________
Employer _____________________________________________________________________________
Address ______________________________________________________________________________
City ____________________________ State ____ Zip ________ Home Phone ___________________
Work phone (______) ______ - __________ Cellular phone/Pager/Etc. (______) ______ - ____________
Driver’s License # ____________________ (State)_________ Email_____________________________
Alternate Contact (Name) _________________________________ (Relationship)_________________________
Home Phone____________________ Work Phone__________________ Cell Phone_________________
Emergency Contact (Name) __________________________________ (Relationship)______________________
Home Phone____________________ Work Phone___________________ Cell Phone________________
How were you (was your student) referred to RES? __________________________________________________
Legal Alert: Is anyone legally restricted from contact with your student? (Circle one) Yes No
Are copies of documents on file? (Circle one) Yes No
For Administrative Use Only:
Official Enrollment Date _____/ _____/ _____
Official Withdrawal Date _____/ _____/ _____
(Official enrollment date is first day of attendance; official withdrawal date is indicated on withdrawal form and attendance records.)
2011-12
Affidavit of Student Residency
Student
(Last Name)
(First Name)
(Middle Name)
Student lives with the following person(s):
_______________________________________ and/or_________________________________________
First and Last name of Father/Stepfather/Grandfather/Other
(Circle One)
First and Last name of Mother/Stepmother/Grandmother/Other
(Circle One)
At the Following Address:
Street Address
City
Zip
Phone
Texas Education Code § 25.001 authorizes Texas school districts to obtain evidence that a person is eligible to attend the public schools
of the district at the time of enrollment. To be eligible for continued enrollment in Responsive Education Solutions, the parent or guardian
of a student must show proof of residency at the time of enrollment. To comply with residency requirements, the parent or guardian of a
student must return this document to Responsive Education Solutions with an original of at least two of the following documents showing
name and verifiable current address. (Documents showing evidence of any alteration will not be accepted.)
Parent / Guardian must provide at least two (2) of the following documents:
_______ Current Utility Bill in parent/guardian’s name _______ Current Texas Driver’s License with current residential address
_______ Executed lease agreement
_______ Deed of Sale
Signature of Parent or Guardian
________ Tax Statement
Date
I affirm that I have seen and reviewed the verification of residency.
_______________________________________,
Signature of School Official
____________________________ __________________________
Position
Date
Photo / Video Release
I, (Name of parent / guardian) _______________________________, do hereby give or grant permission to and assign all rights in and to
any photographs, motion pictures, video footage, and/or audio recordings that may be taken of my child during his/her attendance at
Responsive Education Solutions that may be used for promotional or training purposes. I hereby authorize the above-named entities to
reproduce, copy, exhibit, publish, and distribute any and all photographs, motion pictures, video footage, and/or audio recordings for the
sole purpose of promoting the RES learning system or training and professional development of staff. I certify that I am over the age of
twenty-one (21).
(Signed) ___________________________________________________ parent / guardian
PLEASE NOTE: Signing this form is not a condition of enrollment. RES, however, greatly appreciates your cooperation.
Notice of Compulsory Attendance Law This notice is to advise you that according to Section 25.085 of the Texas Education
th
Code, children between the ages of six (6) and their 18 birthday are required to attend school on a daily basis unless specifically exempted
by Section 25.086. A child who is required to attend school under this section shall attend school each day for the entire period the program
of instruction is provided. The law places the responsibility on parents or those who stand in parental relationship to see that children attend
school regularly. Any parent or person failing to require his child to attend school as required by law may be subject to a fine–an offense
under this section is a Class C Misdemeanor and is punishable by a fine of UP TO $500 for each offense. Section 25.095 states that a
parent will be notified in writing if a child is absent 10 days or parts of days during a six-month period or three (3) or more days or parts of
days during a four-week period. Responsive Education Solutions will enforce these laws as stated by the Education Code and will report all
offenses to the local authorities. By signing below I am acknowledging the receipt of this notification.
A person who knowingly falsifies information on a form required for a student’s enrollment in Responsive Education Solutions shall be liable to RES if
the student is not eligible for enrollment and is enrolled on the basis of false information. For the period in which the student is enrolled, the person is
liable for the maximum tuition fee the District may charge or the amount the District has budgeted per student as maintenance and operating expense,
whichever is greater. Texas Education Code § 25.031(g)
Student signature_______________________________________________________ Date____/ _____ / _____
(Custodial) Parent/Guardian signature ______________________________________ Date____ / _____ / _____
I affirm that I have seen and reviewed enrollment and residency information of the above student.
Registrar signature _____________________________________________________ Date____ / _____ / _____
2011-12
Home Language Survey
Cuestionario del Idioma en el Hogar
All questions must be answered completely. PLEASE PRINT
Las preguntas deberán ser respondidas por completo. FAVOR ESCRIBIR EN LETRA DE MOLDE
Student / Estudiante___________________________________________________ Age / Edad __________
Campus / Escuela ____________________________________________________ Grade / Grado ________
Schools are required by Texas law to determine the following information for all students. Please help us meet this requirement by answering every
question and signing and dating the form. A parent, guardian or student may sign when the student is in ninth grade or higher; otherwise, a parent or
guardian must sign.
1. In what month and year did the student first enroll in a school in the United States? ___________ _________
Month
Year
2. In what city, state, and country was the student born? ____________________ ___________ ___________
City
State
Country
3. What language is spoken in your home most of the time? ______________________________
4. What language does the student speak most of the time? ______________________________
5. Does the parent of guardian need to communicate with the school in a language other than English? _______
If yes, write the name of the language. ________________________________________________________
OR…
Bajo la Ley de Texas se requiere que las escuelas determinen la siguiente información por cada estudiante. Por favor, ayúdenos por contestar
cada pregunta y por firmar y notar la fecha. Cuando el estudiante esté cursando el noveno grado o uno más alto, pueden firmar el padre, la
madre, el guardián, o el estudiante. De otra manera, solamente pueden firmar los padres o los guardianes.
1. ¿En qué mes y año se inscribió el estudiante por primera vez en Los Estados Unidos? ___________ _________
Mes
Año
2. ¿En qué ciudad, estado, y país nació el estudiante? ____________________ ____________ ____________
Ciudad
Estado o provincia
País
3. ¿Cuál es el idioma que más se habla en su casa? ______________________________
4. ¿Cuál es el idioma que más habla el estudiante? _______________________________
5. Necesitará el padre, la madre, o el guardián comunicarse con la escuela utilizando un idioma que no sea el
Inglés? Subraye la respuesta correcta.
Sì
No
Si es así, favor escribir el nombre del idioma. __________________________________
Signature (Firma)_________________________________________ Date (Fecha)___________
2011-12
Special Education/Child Find
Student’s Name _______________________________ Date of Birth _________________
Was this student receiving Special Education services at the last school the
YES
NO
student attended? (ARD, IEP, BIP)
If yes, please specify: (Check any that apply)
Content Mastery/Resource Room
Counseling
Speech Therapy
Occupational/Physical Therapy
Behavior Adjustment Class
Other:
If you answered "NO" above, then…
Was this student ever identified as a Special Education student?
YES
NO
School
Name:
School
Year:
Has the student ever received 504 Services/Accommodations?
YES
NO
School
Name:
School
Year:
_____________________________
Parent Signature
_____________________
Date
2011‐12
Student Health History
Date ____________________________
Student: ____________________________________________ Phone #
LAST
FIRST
(_______) - _______ -_______
MIDDLE
Social Security # ______ - _____ - ______ D.O.B. ____ /_____ /_______ Campus_________________________
Student resides with Parent(s) ___________________ Spouse ____________________ Other _________________
NAME
NAME
NAME
Is student pregnant? Yes ___ No ___ If yes, expected due date ___ / ___ / ___ Doctor _____________________
NAME AND PHONE #
Please list student allergies to medicine, food, environmental, or other that you are aware of or suspect:
Please identify if student has had the following diseases by writing the age he/she had the disease on the line:
Chickenpox ________ Measles ________ Mumps ________
AGE
AGE
AGE
Please check any of the following illnesses, injuries, or conditions which student has had or currently has:
PLEASE INDICATE IF IT IS A PAST OR PRESENT CONDITION / DOCTORS / CURRENT MEDICATION REQUIREMENTS AND PURPOSE.
FAVOR DE INDICAR SI LA CONDICION ES PASADO O PRESENTE / DOCTORES / MEDICACION REQUIRIDO Y SU PROPOSITO.
___ Asthma or Lung Problems _________________________________________________________________
ASMA / PROBLEMAS DEL PULMON
___ Diabetes/Hepatitis _______________________________________________________________________
DIABETES / HEPATITIS
___ Ear/Nose/Throat _________________________________________________________________________
OIDO / NARIZ / GARGANTA
___ Epilepsy/Seizures________________________________________________________________________
EPILEPSIA / ATAQUES EPILEPTICOS
___ Fracture/Dislocation/Strain _________________________________________________________________
FRACTURAS / LUXACIONES
___ Hearing Aid/Orthopedic Braces _____________________________________________________________
APARATO AUDITIVO / ORTHOPEDICO
___ Head Injury _____________________________________________________________________________
GOLPES DE LA CABEZA
___ Heart Problems __________________________________________________________________________
PROBLEMAS DEL CORAZON
___ Kidney Problems _________________________________________________________________________
PROBLEMAS DEL RINON
___ Ulcers/Digestive _________________________________________________________________________
ULCERAS / PROBLEMAS DIGESTIVOS
___ Skin/Toes ______________________________________________________________________________
PROBLEMAS DE LA PIEL
___ Surgery ________________________________________________________________________________
CIRUGIAS
___ Other: i.e., ADHD/AIDS etc.
OTRAS PROBLEMAS: EJEMPLO, PROBLEMAS CON ATENCION A SIDAS, ETC.
Is student currently under the care of a doctor for any problem not discussed above? Please provide details on back.
SI ESTA RECIBIENDO ATENCION MEDICA POR QUALQUIER OTRA RAZON, FAVOR INDICAR CON QUIEN Y PARA QUE. NECESITAMOS LOS DETALLES.
2011-12
School Year: 20___ - 20___
Occupational Survey
Your Children May Be Eligible for Extra Services
IMPORTANT: Please complete the survey below and return it to your school office.
Name of Student_____________________________________________Grade________________
Within the past three (3) years, has your child(ren) traveled or moved alone with a parent, Yes ____ No ___
relative, guardian, or a spouse so that a family member could look for or do temporary or
seasonal agricultural work or employment?
Signature of Parent/Guardian_____________________________ Date ___________________________
If No, please stop here and hand this survey back to your school district.
If YES, please (√) the type of employment and complete the following contact information below.
Farming
Picking fruit or vegetables
Plant nursery
Ranching
Cotton farming/ginning
Poultry production
Fencing
Combining/harvesting grain
Clearing land
Dairying
Driving tractors, machinery
Picking pecans, etc.
Fishing
Tree growing or harvesting
Bailing hay
Food processing in plants
Other similar work
Contact Information
Name of Child(ren)____________________________________________________________________
Father/Guardian __________________________ Mother/Guardian____________________________
Home Address________________________________________________________________________
Street
City
State
ZIP
Home Phone (____) _________________________ Other Phone (____) _________________________
2011-12
Formulario De Trabajo
Sus Hijos Podrían Recibir Servicios Extras
IMPORTANTE: Por favor complete este formulario y regréselo a la escuela.
Nombre de Estudiante ______________________________ Grado/Curso _________________
¿Durante los últimos tres (3) años, viajó o se fue su hijo/a a vivir solo/a con sus Sí ____ No ___ padres, algún
guardián legal, o esposo/a para que alguno de la familia buscara o encontrara trabajo temporal en la
agricultura?
Firma de Padres/Guardían __________________________________Fecha _______________________
Si contestó No, no es necesario seguir completando este formulario. Sólo regréselo a la escuela, a la
brevedad.
Si contestó Sí, por favor indique con un (√) y complete la siguiente información de contacto abajo.
En la cosecha
Recogiendo frutas/verduras
En guardería de plantas
En ranchos/
En el algodón
En producción de aves
ranchería
Cosechando granos
Limpiando terrenos
En las cercas
En el manejo de tractores, maquinaria
Recogiendo nuez, etc.
En lecherías
Plantando árboles
Recogiendo paja
En la pesca
Procesando comida en fábricas
Algún otro trabajo similar
Referencia
Hijo(s)______________________________________________________________________________
Padre/Guardián ____________________________Madre/Guardián_____________________________
Domicilio____________________________________________________________________________
Calle
Ciudad
Estado
ZIP
Teléfono del hogar (____) _____________________ Otro teléfono (____) ________________________
2011-12
Student Record Release
DATE ____________________
To Releasing School Counselor or Registrar:
School Name:
School Address:
City, State, Zip:
School Telephone:
Fax Number:
The following student has withdrawn from your school.
Student
Student ID #
Date of Birth
Please forward the following information on the above student:
___ Official Transcript
___ Academic Records
___ Testing Scores/Assessment
___ Health Records
___ Special Ed Classification / Documents
___ Copy of Birth Certificate
___ Copy of Social Security Card
___ Other
Please respond to the following address:
TXVA
1800 Lakeway Drive, Suite 100
Lewisville, TX 75057
Signature of Guardian or Registrar
Date
2011-12
STATE COMPENSATORY EDUCATION ALLOTMENT
2011-12 ELIGIBILITY GUIDELINES
Please circle one number in the “Family Size” column, and only one income amount on that same row.
This information will assist us to provide additional materials, computer hardware, telecommunications,
and Internet service for our students. Thank you for your assistance.
Family
Size
If your income is
annual, please
use the amounts
below.
If your income is
monthly, please
use the amounts
below.
If your income is
twice per month,
please use the
amounts below.
If your income is
every two weeks,
please use the
amounts below.
Less than the following
annual amount:
Less than the following
monthly amount:
Less than the following
twice per month
amount:
Less than the following
two-week amount:
1
$14,157
$20,147
$1,180
$1,679
$590
$840
$545
$775
2
$19,123
$27,214
$1,594
$2,268
$797
$1,134
$736
$1,047
3
$24,089
$34,281
$2,008
$2,857
$1,004
$1,429
$927
$1,319
4
$29,055
$41,348
$2,422
$3,446
$1,211
$1,723
$1,118
$1,591
5
$34,021
$48,415
$2,836
$4,035
$1,418
$2,018
$1,309
$1,863
6
$38,987
$55,482
$3,249
$4,624
$1,625
$2,312
$1,500
$2,134
7
$43,953
$62,549
$3,663
$5,213
$1,832
$2,607
$1,691
$2,406
8
$48,919
$69,616
$4,077
$5,802
$2,039
$2,901
$1,882
$2,678
$295
$191
$272
For each additional family member add:
$4,966
$7,067
$414
$589
$207
My family income is greater than those listed above. (Please check box)
Do you receive Food Stamps? If you wish, circle the correct response:
Yes
No
Please sign below:
________________________________________________
Parent/Guardian Name (Signature)
________________________________________________
Student Name (Printed)
____________________
Date
____________________
Grade Level
2011-12
Texas Education Agency
Texas Public School Student/Staff Ethnicity and Race Data Questionnaire
The United States Department of Education (USDE) requires all state and local education
institutions to collect data on ethnicity and race for students and staff. This information is used
for state and federal accountability reporting as well as for reporting to the Office of Civil Rights
(OCR) and the Equal Employment Opportunity Commission (EEOC).
School district staff and parents or guardians of students enrolling in school are requested to
provide this information. If you decline to provide this information, please be aware that the USDE
requires school districts to use observer identification as a last resort for collecting the data for
federal reporting.
Please answer both parts of the following questions on the student’s or staff member’s ethnicity
and race. United States Federal Register (71 FR 44866).
Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one.)
Hispanic/Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin, regardless of race
No Hispanic/Latino
Part 2. Race: What is the person’s race? (Choose one or more.)
American Indian or Alaska Native – A person having origins in any of the original peoples of
North and South America (including Central America) and who maintains a tribal affiliation or
community attachment
Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or
the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and Vietnam
Black or African American – A person having origins in any of the black racial groups of
Africa
Native Hawaiian or Other Pacific Islander – A person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific Islands
White – A person having origins in any of the original peoples of Europe, the Middle East, or
North Africa
________________________________
________________________________
Student Name (please print)
Parent or Guardian Signature
________________________________
________________________________
Student Identification number
Date
Texas Education Agency – March 2009
Agencia de Educación de Texas
Cuestionario de Información de Datos Raciales y de Etnicidad de Estudiantes/Miembros de
Personal de las Escuelas Públicas de Texas
El Departamento de Educación de Estados Unidos (USDE) requiere que todas las instituciones
estatales y locales de educación, recopilen datos sobre etnicidad y raza de los estudiantes y de
miembros de personal. Esta información es utilizada para los reportes estatales y federales así
como para reportar a la Oficina de Derechos Civiles (OCR) y a la Comisión de Igualdad en el
Empleo (EEOC).
Al personal del distrito escolar y los padres o representante legal de estudiantes que deseen
matricularse en la escuela, se le requiere proporcionar esta información. Si usted rehúsa
proporcionarla, es importante que sepa que el USDE requiere que los distritos escolares usen la
observación para identificación como último recurso para obtener estos datos utilizados para
reportes federales.
Favor de contestar ambas partes de las siguientes preguntas sobre la etnicidad y raza del
estudiante así como del miembro de personal. Registro Federal de Estados Unidos (71 FR 44866).
Parte 1. Etnicidad: ¿Es la persona Hispana/Latina? (Escoja solo una respuesta.)
Hispano/Latino – Una persona de origen cubano, mexicano, puertorriqueño, centro o sudamericano
o de otra cultura u origen español, sin importar la raza
No Hispano/Latino
Parte 2. Raza. ¿Cuál es la raza de la persona? (Escoja uno o más de uno.)
Indio Americano o Nativo de Alaska – Una persona con orígenes o de personas originarias
de Norte y Sudamérica (incluyendo America Central) y que mantiene lazos o apego
comunitario con una afiliación de alguna tribu
Asiático – Una persona con orígenes o de personas originarias del Lejano Este, Sureste de Asia, o el
subcontinente indio, incluyendo, por ejemplo a Cambodia, China, India, Japón, Corea, Malasia,
Pakistán, las Islas Filipinas, Tailandia y Vietnam
Negro o Áfrico-Americano – Una persona con orígenes de cualquier grupo racial negro de
África
Nativo de Hawai u otras islas del pacífico – Una persona con orígenes o de personas
originarias de Hawai, Guam, Samoa u otras Islas del Pacífico
Blanco – Una persona con orígenes de personas originarias de Europa, el Medio Este, o el
Norte de África
________________________________________
________________________________
Nombre del Estudiante
(por favor use letra de imprenta)
Firma (Padre o Representante legal)
________________________________
________________________________
Número de Identificación del
Estudiante
Fecha
Agencia de Educación de Texas – Marzo 2009
AT RISK INDICATORS / DOCUMENTATION
Student Name ______________________________________________
Date __________________
A student at-risk of dropping out of school includes each student who is under 21 years of age and who:
(Check yes or no)
YES
NO
2. Is in grade 7, 8, 9, 10, 11, or 12 and did not maintain an average equivalent to 70 on a scale
of 100 in two or more subjects in the foundation curriculum during a semester in the preceding
or current school year or is not maintaining such an average in two or more subjects in the
foundation curriculum in the current semester.
3. Was not advanced from one grade level to the next for one or more school years.
4. Did not perform satisfactorily on an assessment instrument [TAAS/TAKS] administered to the
student under TEC Subchapter B, Chapter 39, and who has not in the previous or current
school year subsequently performed on that instrument or another appropriate instrument at a
level equal to at least 110 percent of the level of satisfactory performance on that instrument.
5. Is pregnant or is a parent.
6. Has been placed in an alternative education program in accordance with TEC §37.006 during
the preceding or current school year.
7 Has been expelled in accordance with TEC §37.007 during the preceding or current school
year.
8. Is currently on parole, probation, deferred prosecution, or other conditional release.
9. Was previously reported through the Public Education Information Management System
(PEIMS) to have dropped out of school.
10. Is a student of limited English proficiency, as defined by TEC §29.052.
11. Is in the custody or care of the Department of Protective and Regulatory Services or has,
during the current school year, been referred to the department by a school official, officer of
the juvenile court, or law enforcement official.
12. Is homeless, as defined by 42 U.S.C. Section 11302, and its subsequent amendments; or
13. Resided in the preceding school year or resides in the current school year in a residential
placement facility in the district, including a detention facility, substance abuse treatment
facility, emergency shelter, psychiatric hospital, halfway house, or foster group home.
1. Is in prekindergarten, kindergarten or grade 1, 2, or 3 and did not perform satisfactorily on a
readiness test or assessment instrument administered during the current school year.
The Student is at risk – (Check Yes or No)
Principal Signature: __________________________________________ Date: __________________________
Parent / Guardian Signature: _______________________________ Date: __________________________
2011-2012
WITHDRAWAL INTENT FORM
If I, ________________________ (parent/guardian) should decide that TXVA is
not the appropriate place for my student___________________, my preferred
educational intent to school will be the following:
Home School
Private School
*Name of Public School (if this is the choice, this information must be
completed and is not optional):
__________________________________
Address: __________________________
Phone Number: ____________________
*Responsibility for compliance with state attendance statutes and regulations belongs to the
parents, but the school is obligated to keep an accurate record of daily attendance. By statute,
if a student is not meeting the statutory requirements for public school attendance, the student
is considered truant under TEC 25.094.
This statute defines truancy as:
*not being in attendance 10 or more days within a six-month period and/or
*not being in attendance 3 or more days within a 4-week period
As a truant student:
1. The student's parent or legal guardian is subject to prosecution under Texas
Education Code 25.093.
2. The student is subject to prosecution under Texas Education Code 25.094. A fine of
$500.00 may be assessed.
Parent/Guardian Signature: ________________________________
Date: _____________
TXVA 2011