Parent Signature. (Name in print) ............................................ Date ............................................
Parent Signature. Yes, I give consent for Jefferson School District to access my public benefits for my child’s health services.
Parent Signature. I declare, under penalty of perjury, that I will adhere to the requirements outlined above and that all information provided is true and accurate. I understand that I have not been officially approved for services until I receive my Notice of Action (NOA). Parent/Guardian Signature Date
Parent Signature. Date: I agree to maintain two-way communication with my assigned mentor teacher on a weekly basis throughout my enrollment (exceptions during winter and spring break only). I agree to meet at my predetermined times and dates, either at the resident district or by telephone, once per week with my assigned mentor teacher. This arrangement is made between my assigned mentor teacher and me upon my enrollment.
Parent Signature. Date: ………………
Parent Signature. In school it is important that I work to the best of my ability. In order to do this, I will try to do the following:
Parent Signature. I agree that I will provide the babysitter with diapers, extra clothing, special food, or any other necessary items. I agree that I will also provide the babysitter with instructions regarding feeding schedules, nap and bedtime schedules, and any other necessary instructions to care for my child(ren). I understand that by signing this form, I am trusting my child(ren)’s safety and welfare to the above named babysitter, and that I am holding the shelter, hotel or other EA placement and DHCD harmless if my child(ren) is(are) injured or not cared for as I would like. Parent Signature:
Parent Signature. 🞏 I understand that all students must have at least one (1) burgundy school shirt.
Parent Signature. (School Year: 2018-2019)
Parent Signature. Provider Signature:
