Irving Independent School District Forms (Page 5 of 7) in pdf

Irving ISD

057912

ADMISSIONS

(EXHIBIT)

EXHIBIT B

IRVING INDEPENDENT SCHOOL DISTRICT

AFFIDAVIT OF STUDENT ADMISSION INFORMATION

(FOR NONRESIDENT STUDENT IN A GRANDPARENT’S AFTER-SCHOOL CARE)

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 _____________________

______________________ and ________________________________, known to me to be

the persons whose names are subscribed below, who, upon being duly sworn, stated:

To be completed by the parent or guardian:

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.

My name is ________________________________________. I am the parent or legal

guardian of _________________________________________ for whom I am request-

ing admission to the _________________________________ School District under

Education Code 25.001(b) (9).

This child and I reside at _______________________________________________ in

the ______________________________ Independent School District. My telephone

number is _________________.

This child is __________ years of age on September 1 of this scholastic year and cur-

rently attends ____________________________________________ in that district.

This child’s grandparent, ______________________________________________, will

provide my child after-school care as follows:

Actual hours per day: ______________ a.m./p.m. to ______________ a.m./p.m.

Number of school days per week: __________________________

Months that the child’s grandparent will provide this care: ________________

I agree to notify the Superintendent within three school days of any changes to the af-

ter-school care described above.

I (do) (do not) authorize the employees of the Irving Independent School District to con-

tact the child’s grandparent identified below for nonemergency purposes. Contact for

emergency purposes shall be as I have indicated on the District’s Emergency Contact

Information Card.

DATE ISSUED: 2/6/2006

1 of 2

LDU-06-06

FD(EXHIBIT)-X

Irving Independent School District Forms Page 5