Irving Independent School District Forms (Page 3 of 7) in pdf

Irving ISD

057912

ADMISSIONS

(EXHIBIT)

EXHIBIT A

IRVING INDEPENDENT SCHOOL DISTRICT

AFFIDAVIT OF STUDENT ADMISSION INFORMATION

(FOR STUDENT LIVING SEPARATE AND APART FROM PARENT OR GUARDIAN)

NOTICE TO PERSON ENROLLING THE STUDENT: A person who knowingly falsifies in-

formation on a form required for a student’s enrollment in the District shall be liable to the

District for tuition or other costs, as provided in Education Code 25.001(h), if the student is

not eligible for enrollment but is enrolled on the basis of false information. In addition, pre-

senting false information or false records is a criminal offense under Penal Code 37.10.

BEFORE ME, the undersigned notary public, personally appeared _____________________

______________________________, known to me to be the person whose name is sub-

scribed below, who, upon being duly sworn, stated:

My name is __________________________________________. I am over 18 years

of age and am legally competent to testify. I have personal knowledge of the facts set

forth herein, and they are true and correct.

___________________________________________ seeks admission as a student to

the Irving Independent School District.

The child is __________ years of age on September 1 of this scholastic year.

The child currently resides at

The name(s) and address(es) of the parent(s) or legal guardian(s) of the child are:

My relationship to the child is

The child’s presence in the Irving Independent School District is not for the primary pur-

pose of participation in extracurricular activities. The child has established a residence

separate and apart from the child’s parent, guardian, or other person having lawful con-

trol of the child under order of a court.

The child:

(Has) (has not) engaged in conduct or misbehavior within the preceding year that

has resulted in removal to a Disciplinary Alternative Education Program or expul-

sion;

(Has) (has not) engaged in delinquent conduct or conduct in need of supervision

and (is) (is not) on probation or other conditional release for such conduct;

(Has) (has not) been convicted of a criminal offense and (is) (is not) on probation

or other conditional release.

DATE ISSUED: 2/6/2006

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LDU-06-06

FD(EXHIBIT)-X

Irving Independent School District Forms Page 3