COMPTON UNIFIED SCHOOL DISTRICT

OFFICE USE ONLY
Student ID# _____________
Date Recv’d: ____________
Please indicate your choice(s) for the Supplemental Educational Services Provider for your child. Please
complete this form and return it before leaving. Por favor indique su preferencia para los servicios
supleméntales para su hijo/a. Por favor entregue este formulario antes de partir esta feria.
FOR
COMPTON UNIFIED SCHOOL DISTRICT
2015-2016 Parent – Provider Selection Form
Supplemental Educational Services (SES)
Student Last Name/Apellido del Estudiante :___________________ First/Nombre: ________________
Date of Birth/Fecha de Nacimiento: ________________________________________
Telephone/Teléfono: _____________________________________________________
City/Zip Code/Ciudad/Coligo Postal: _______________________________________
Cell/Celular: ____________________________________________________________
Parent/Guardian Name/Nombre Padre/Tutor: ________________________________
SCHOOL/Escuela: _________________________________________________________
PROVIDER
Home Address/Domicilio: _________________________________________________
Grade/Grado: ________________________
My 1st choice for my child’s Supplemental Services Provider is:
Mi primera preferencia para mi hijo/a es:
My 2nd choice for my child’s Supplemental Services Provider is:
Mi segunda preferencia para mi hijo/a es:
________________________________________________________________________
USE
________________________________________________________________________
My 3rd choice for my child’s Supplemental Services Provider is:
Mi tercera preferencia para mi hijo/a es:
________________________________________________________________________
________________________________
PARENT SIGNATURE/Firma de padre
SES Selection Form – Eng-Spa 2015-2016
______________________
Date/Fecha
ONLY
I GIVE PERMISSION for Compton Unified School District to release my child(s) information to the above selected
Supplemental Educational Services Provider (tutor). Doy mi autorizacion al Distrito Escolar Unificado de Compton
para que de informacion sobre mi hijo/a al Proveedor de Servicios Educativos Suplementales (tutor) indicado arriba.