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SAN FELIPE DEL RIO CISD

233901 FD

ADMISSIONS (EXHIBIT)

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See the following forms relating to student enrollment:

Exhibit A: Power Of Attorney and Evidence of Legal Authority of Adult Responsible for

Student to Substitute for a Guardian or Other Person Having Lawful Control of

a Child for Purposes of Admission and Enrollment — 2 pages

Exhibit B: Residency Verification Affidavit— 2 pages

Exhibit C: Notice of Revocation of Authorization Agreement — 1 page

Exhibit D: Request for Food Allergy Information — 1 page

Exhibit E: Request for Information on Military-Connected Students — 1 page

SAN FELIPE DEL RIO CISD

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EXHIBIT A

SANȱFELIPEȱDELȱRIOȱ

VÉÇáÉÄ|wtàxw \ÇwxÑxÇwxÇà fv{ÉÉÄ W|áàÜ|và

POWER OF ATTORNEY AND EVIDENCE OF LEGAL AUTHORITY OF ADULT

RESPONSIBLE FOR STUDENT TO SUBSTITUTE FOR A GUARDIAN OR

OTHER PERSON HAV I N G LAW FUL CONTROL OF A CHILD

FOR

PURPOSES OF ADMISSION AND ENROLLMENT

I, ____________________________________________________________, am the parent or legal

ARENT/GUARDIAN NAME

guardian of _____________________________________, a student enrolling for admission or

TUDENT NAME

enrolled in the San Felipe Del Rio Consolidated Independent School District and residing with

_____________________________________ his/her _____________________________ at

AME OF ADULT RESPONSIBLE RELATIONSHIP TO STUDENT

___________________________________________, a residential address which I affirm to be located

DDRESS WHERE STUDENT RESIDES

within the geographical boundaries of San Felipe Del Rio Consolidated Independent School District

(“SFDRCISD” or “the District”) for purposes of establishing the residence of my child or ward to satisfy

the eligibility requirements for attending tuition-free public school in Texas as set forth in Texas Educa-

tion Code Section 25.001 and District Policy FD (LOCAL).

I hereby convey to the Responsible Adult named above my Power of Attorney to act as my agent

in any lawful way with respect to my child’s or ward’s attendance in SFDRCISD including, but not

limited to, the following:

a) Provide and receive information and school records, and all other rights afforded to parents

under the Family Educational Rights and Privacy Act, 20 U.S.C. 1232(g);

b) Access my child’s student records described in Tex. Educ. Code Sec. 26.004, including rec-

ords related to school attendance, grades, discipline, admissions, counseling, testing, health

and immunization, behavioral evaluations, and psychological evaluations;

c) Interact with District staff regarding campus and class assignments, counseling, field trips,

transportation, travel, progress reports, and graduation requirements;

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d) Represent my child’s interests regarding special education and/or 504 related classes or pro-

grams and/or hearings, state testing/evaluation;

e) Receive notifications concerning medical problems and the right to give consent for the

medical care and treatment of the child; and

f) Any other rights and responsibilities set forth in Chapter 26 of the Texas Education Code.

I agree that SFDRCISD, its employees and agents, may act under this document until said par-

ties receive actual written notice of a revocation of this Power of Attorney, and I agree to indemnify

and hold harmless SFDRCISD and said parties from any claims that may be construed and interpreted

as a general power of attorney and my agent shall have the power and authority to perform and undertake

any action I could perform or undertake if I were personally present.

I intend for this Power of Attorney to be effective immediately and for it not to be affected by

my subsequent disability or incapacity. My consent for this Power of Attorney is voluntarily given, and

I understand that I may revoke this consent at any time by notifying, in writing, the campus principal. I

agree that any third-party who receives a copy of this document may act upon it. This Power of Attorney

is not assignable to any other party.

I understand that the mere execution of this Power of Attorney does not entitle my child or ward

to attend school in SFDRCISD, as attendance is determined by Texas law and SFDRCISD Board Policy

that additionally requires the responsible adult described above to complete and submit a properly com-

pleted and notarized Residency Verification Affidavit (FD (Exhibit B)) and other proofs of residence.

Therefore, I further grant authority to SFDRCISD to gather all records and to investigate and make such

inquiries as it may deem necessary to determine whether my child or ward is eligible for tuition-free

attendance including, but not limited to furnishing SFDRCISD with additional proof of residency as

described in SFDRCISD Board Policy FD (LOCAL) conducting home-visits to the physical address of

my Agent or other address on record for my child or ward to verify that my child or ward does in fact

reside at that address, and any other reasonable and lawful investigatory measures necessary to confirm

that the declarations in this Power of Attorney are true.

I further affirm that my child’s presence in SFDRCISD is not for the primary purpose of partic-

ipating in extracurricular activities.

By signing this document before a Notary Public in the State of Texas, I affirm that I have

read and understood the foregoing statements and further affirm that these statements are true, to the

best of my knowledge, and that falsifying any information or documentation for the purpose of unlaw-

fully securing tuition-free public education for my child or ward will constitute perjury and shall author-

ize SFDRCISD to pursue all allowable civil and criminal penalties.

I have been informed and understand that under Section 37.10 of the Texas Penal Code, a person

who knowingly falsifies information on a student’s enrollment form has committed a criminal offense.

Such person is also liable for tuition for the period during which the ineligible student is enrolled, under

Texas Education Code Section 25.001(h).

_________________________________________

AME OF STUDENT’S PARENT

SAN FELIPE DEL RIO CISD

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_____________________________________________________

DDRESS

___________________________________ ____________________ ____________

ITY STATE ZIP CODE

____________________________

HONE NUMBER

ITNESS MY HAND AT ______________________________, TEXAS ON THE _____ DAY OF

LACE OF SIGNING

____________________, 20___.

___________________________________________

ARENT’S SIGNATURE

SWORN TO AND SUBSCRIBED BEFORE ME THIS THE _____ DAY OF _________________________,

20___.

________________________________________

NOTARY PUBLIC, STATE OF TEXAS

________________________________________ (SEAL)

TYPED OR PRINTED NAME OF NOTARY

________________________________________

COMMISSION EXPIRATION DATE

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EXHIBIT B

SANȱFELIPEȱDELȱRIOȱ

VÉÇáÉÄ|wtàxw \ÇwxÑxÇwxÇà fv{ÉÉÄ W|áàÜ|và

RESIDENCY VERIFICATION AFFIDAVIT

To be completed by the adult, other than a student’s parent or guardian, with whom the student resides:

TATE OF TEXAS §

_______________ C

OUNTY §

BEFORE ME, the undersigned notary, on this day appeared____________________, a person whose

identity is known to me. After I administered an oath to him/her in person, upon his/her oath said:

1) My name is _______________________. I am capable of making this affidavit. The facts stated

in this affidavit are within my personal knowledge and are true and correct.

2) My place of residence is at ___________________, a location that is within the geographical

boundaries of the San Felipe Del Rio Consolidated Independent School District (“SFDRCISD” or “the

District”).

3) A student, _______________________, between the ages of five (5) and twenty-one (21) is

enrolled at or wishes to enroll at an SFDRCISD Campus. The student resides with me at my above-

described place of residence

4) I have been duly authorized through the District’s required notarized Power of Attorney form,

executed by the student’s parent or guardian and notarized by a State of Texas Notary Public, to make

decisions related to the well-being of the student, to enroll the student in a Texas public school and to

assume and exercise parental rights and responsibilities, including but not limited to those set forth in

Texas Education Code, Chapter 26. An original executed, properly notarized Power of Attorney form

has been submitted or is contemporaneously submitted to the SFDRCISD Department of Student and

Family Services.

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5) I understand that this Affidavit is necessary but not sufficient to meet District enrollment eligi-

bility criteria. This Affidavit must be accompanied by the above-described Power of Attorney and at

least one of the following supporting documents verifying that my current place of residence is within

the geographical boundaries of the District:

a) rent payment receipt; and/or

b) valid lease agreement; and/or

c) recent utility bill (no more than one month prior), i.e. electrical, water, cable, or

telephone.

I further understand that failure to produce at least one of these documents will render this Affidavit

ineffective for purposes of establishing this student’s enrollment eligibility.

By my signature below I acknowledge my understanding that it is a criminal offense in the State of

Texas to falsify information on a student enrollment form, such as this Affidavit, and that I may be

personally liable for tuition payments to the District if it is later discovered that the student named herein

was ineligible to enroll at SFDRCISD. See Tex. Pen. Code § 37.10(c)(3); Tex. Educ. Code § 25.001(h).

ITNESS MY HAND AT ______________________________, TEXAS ON THE _____ DAY

PLACE OF SIGNING

____________________, 20___.

___________________________________________

IGNATURE

SWORN TO AND SUBSCRIBED BEFORE ME THIS THE _____ DAY OF _________________________,

20___.

________________________________________ (SEAL)

NOTARY PUBLIC, STATE OF TEXAS

________________________________________

TYPED OR PRINTED NAME OF NOTARY

________________________________________

COMMISSION EXPIRATION DATE

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EXHIBIT C

NOTICE OF REVOCATION OF AUTHORIZATION AGREEMENT

A copy of your Authorization Agreement must be submitted with this notice.

Date: ___________________

This notice is to inform San Felipe Del Rio Consolidated Independent School District that the

Authorization Agreement for _____________________________ (student’s name) has been

revoked, effective _________ (date), in accordance with Section 34.008(c) of the Texas Fam-

ily Code.

Parent name: ______________________________________________________________

Parent signature: __________________________________________________________

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EXHIBIT D

REQUEST FOR FOOD ALLERGY INFORMATION

(The District must request, at the time of enrollment, that the parent or guardian of

each student attending a school in the District disclose the student’s food allergies.

Additional information regarding food allergies, including maintaining records related

to a student’s food allergies, can be found at FD and FL.)

This form allows you to disclose whether your child has a food allergy or a severe food al-

lergy that you believe should be disclosed to the District in order to enable the District to take

necessary precautions for your child’s safety.

“Severe food allergy” means a dangerous or life-threatening reaction of the human body to a

food-borne allergen introduced by inhalation, ingestion, or skin contact that requires immedi-

ate medical attention.

Please list any foods to which your child is allergic or severely allergic, as well as the nature

of your child’s allergic reaction to the food.

Food: Nature of allergic reaction to the food:

The District will maintain the confidentiality of the information provided above and may dis-

close the information to teachers, school counselors, school nurses, and other appropriate

school personnel only within the limitations of the Family Educational Rights and Privacy Act

(FERPA) and District policy. [See FL]

Student’s name: ______________________________________________________

Date of birth: _________________________ Grade: _________

Parent’s/Guardian’s name: __________________________________________________

Work phone: __________________________ Home phone: _____________________

Parent/Guardian signature: ____________________________ Date: ________________

Date form was received by the school: ________________________________________

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EXHIBIT E

REQUEST FOR INFORMATION ON MILITARY-CONNECTED STUDENTS

State law requires the District to collect data related to students with connections to the

military. Please complete the following form, sign at the bottom, and return to your child’s

school.

Student’s name: ___________________________________ Student ID: _____________

Please check all that apply.

For students in kindergarten–grade 12:

 Student is a dependent of an active duty member of the United States military (Army,

Navy, Air Force, Marine Corps, or Coast Guard).

 Student is a dependent of a member of the United States or Texas National Guard

(Army, Air Guard, or State Guard).

 Student is a dependent of a member of a reserve force in the United States military

(Army, Navy, Air Force, Marine Corps, or Coast Guard).

 Student is not a military-connected student as defined above.

[Include this section if your District has a prekindergarten program]

For prekindergarten students:

 Prekindergarten student is a dependent of an active duty member of the United States

military (Army, Navy, Air Force, Marine Corps, or Coast Guard).

 Prekindergarten student is a dependent of an activated/mobilized member of the United

States or Texas National Guard (Army, Air Guard, or State Guard).

 Prekindergarten student is a dependent of an activated/mobilized member of the United

States reserve (Army, Navy, Marine Corps, Air Force, or Coast Guard).

 Prekindergarten student is a dependent of a member of the United States military or re-

serve or Texas National Guard who was injured or killed while serving on active duty.

 Prekindergarten student is not a military-connected student as defined in this form.

Parent signature: ______________________________ Date: __________________