FD(EXHIBIT) - ADMISSIONS

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 information 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, presenting 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 requesting admission to the _________________________________ School District under Education Code 25.001(b)(9).

This child and I reside at__________________________________________________ in the _________________________________School District. My telephone number is ___________________________.

This child is __________ years of age on September 1 of this scholastic year and currently 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 after-school care described above.

I (do) (do not) authorize the employees of the _______________________ School District to contact 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.

Signature of (parent/guardian) Affiant

Typed or Printed Name of Affiant

STATE OF TEXAS

COUNTY OF

SUBSCRIBED AND SWORN TO BEFORE ME on this the __________ day of ________________________, ________.

Notary Public, State of Texas

To be completed by the grandparent who will provide after-school care:

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 grandparent of this child.

I reside at ____________________________________________________________ in the ________________________________School District. My telephone number is ________________________________.

I will assume responsibility for the supervision of this child for the purpose of providing after-school care as described in item 4 above.

I agree to notify the Superintendent within three school days of any changes to the after-school care described above.

Signature of (grandparent) Affiant

Typed or Printed Name of Affiant

STATE OF TEXAS

COUNTY OF

SUBSCRIBED AND SWORN TO BEFORE ME on this the __________ day of ________________________, ________.

Notary Public, State of Texas

Poth ISD

FD(EXHIBIT)-X

LDU-24-06

DATE ISSUED: 6/12/2006