Supplementary Education Lincoln Marti Schools Miami Fl Usa

NO CHILD LEFT BEHIND PROGRAM
STATE-APPROVED SUPPLEMENTAL EDUCATIONAL SERVICES (SES) APPLICATION 2007-2008

Student's Name:	Birth Date:
M-DCPS Student ID #:	Grade:
Current School:	Free or reduced lunch: YES NO
Student's Telephone #:	Alternate Telephone #:
Student's Address:	Apt:	City:
	State:	Zip:

Please Check One Selection

Yes, I want SES tutorial services for my child. (Complete ALL sections below)
To qualify for SES, a student must be eligible to receive free or reduced priced lunch and attend an eligible Title I school.
No, I do not want SES tutorial services for my child. (Sign form at the bottom)

State-Approved SES Provider Selection:

In order to apply for SES, the parent must select three providers in order of preference. Every attempt will be made to place the student with one of the three selected providers. In the event none of these selections are available, the student will be assigned to an alternate provider from the list of State-Approved SES Providers.
IN ORDER FOR A COMPLETED ENROLLMENT FORM TO BE VALID, IT MUST BE SUBMITTED ONLINE, RETURNED TO THE SCHOOL OR AT ONE OF THE SES INFORMATION FAIRS, OR VIA FAX AT (305) 995-2540. THERE MUST BE THREE PROVIDERS SELECTED, INCOMPLETE FORMS MAY RESULT IN A DELAY OF SERVICES BEING DELIVERED.

(1st choice) Provider ID

Name

(2nd choice) Provider ID

Name

(3rd choice) Provider ID

Name

Alternate Contact Information

If you would like to be contacted at a different telephone number(s)/address than what appears above, please complete the following items.

Address:

Apt:

City:

State:

Zip:

Telephone: Secondary Telephone:

Consent for Mutual Exchange of Information

I, , hereby authorize the mutual exchange of records* pertaining to my child or myself, between the MIAMI-DADE COUNTY PUBLIC SCHOOLS (M-DCPS) and the following agencies** to facilitate the development of the SES Student Learning Plan by the assigned SES Provider:
*The specific records to be disclosed pertain to: the student's personal contact information, academic achievement level, and if applicable, information related to the Limited English Proficiency (LEP) Plan and/or the Individual Educational Plan (IEP). The receiving party will not disclose the information to any other party without signed consent.
**AGENCIES: Any State-Approved 2007-2008 Supplemental Educational Services (SES) Provider, under contract with M-DCPS, inclusive of the three (3) identified above.
I certify that I am the parent or legal guardian of the child named above or that I am a student of majority of age and have authority to sign this release and select State-Approved SES under the provisions of the No Child Left Behind Act of 2001.

Parent/Guardian's Signature:

Date:

FM-7000S Rev.(07-07)