FD(EXHIBIT) - ADMISSIONS

APPOINTMENT OF ADULT RESIDENT IN DISTRICT TO ACT FOR PARENT FOR PURPOSES OF CONSENT WHEN CHILD IS LIVING SEPARATE AND APART

THE STATE OF TEXAS

County of:

My name is: . I reside at

Address:

City, State, Zip: Telephone:

District:

This document applies to the following minor child(ren)/ward(s):

Name: Relationship:

Age: Date of Birth:

Name: Relationship:

Age: Date of Birth:

Name: Relationship:

Age: Date of Birth:

If permission is granted by the Board to permit the above-named minor(s) to attend the ____________________________________ public schools, __________________ (District)

I consent to have my child/ward live separate and apart from his or her parent or guardian.

I hereby appoint (Name):

Address:

City, State, Zip: Telephone:

an adult resident of this District, as my attorney, to care for and control my child/ward in all school-related matters with the full power and authority that I might have in such matters.

I agree that this power of attorney may be voluntarily revoked alone by written revocation filed with the Superintendent.

By my signature hereto, under the authority of Texas Family Code, Section 32.001, I hereby give authority to the above-named adult resident to consent to medical treatment for the above-named minor(s) in the event I cannot be contacted.

I authorize the above-named adult to act for me, as my attorney, in any matter requiring my consent or signature in all school-related matters affecting the minor(s). I hereby agree to waive all claims and hold harmless the District, its officers, and employees from all claims arising from their reliance on this consent form.

I understand that this is not a grant of legal guardianship (which only a court may grant).

SIGNED this ____________ day of _________________, ______.

Signature of Parent:

Signature of Parent:

In accordance with the Texas Education Code Section 25.001(d), I certify that the student(s) listed below has established a residence separate and apart from his or her parent, guardian, or other person having lawful control of him or her under an order of a court. I further certify that the student(s) has not established a residence in the District for the primary purpose of participation in extracurricular activities.

I understand that if it is determined that the student(s) has not established a residence separate and apart from his or her parent/guardian, that I am liable to the District for paying tuition as established by Board policy. I also understand that in addition to paying tuition, I am liable for the penalty provided in Section 37.10, Penal Code, for knowingly falsifying information on a form required for enrollment of a student in a school district who otherwise would not be eligible to enroll.

Signature of Adult Acting for Parent:

The State of Texas

County of __________________

Before me, a Notary Public, on this day personally appeared _________________________ ___________________________________ known to me (or proved to me on the oath of _________________________) to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he executed the same for the purposes and consideration therein expressed.

Given under my hand and seal of office this _______ day of _________________. A.D. _______.

Notary Public, state of Texas

(Print name of Notary Public here)

My Commission expires the ________________ day of _______________________, ________.

Harlingen CISD

FD(EXHIBIT)-X

LDU-01-06

DATE ISSUED: 1/2/2006