Student Eligibility Form

STUDENT ELIGIBILITY FORM

Purpose: Use this form to document eligibility for enrollment or program participation, including proof of age, residency, immunization status, and income-based eligibility where applicable. Furnishing false information may lead to denial of enrollment or disciplinary action.

Student Information

Student Name:

Date of Birth:     Student ID (if available):

Parent / Guardian Information (if student is a minor)

Eligibility Criteria and Documentation

Residency: Indicate proofs provided (select all that apply)

Immunization: Immunization record attached     Exemption claimed (provide exemption documentation below)

Household Income & Program Eligibility

Annual Household Income: $     Number in Household:

Income documentation attached:

Supporting Documents Checklist

Certifications, Authorizations, and Acknowledgements

I certify that the information provided on this form and the attached documentation is complete and accurate to the best of my knowledge. I understand that falsification, omission, or misrepresentation of facts may result in denial of enrollment, withdrawal of services, or other administrative actions pursuant to district policy.

I authorize the school district to verify residency, income, and immunization records with third parties and to request relevant student records from prior schools. I further authorize release of student records to agencies and individuals as necessary to determine eligibility for the program(s) indicated on this form.

Privacy Notice: Information collected on this form will be used for enrollment and program eligibility determinations and will be maintained in the student's official educational record. The district will protect personally identifiable information in accordance with applicable policy and law.

By signing below, I affirm that I have read and understand the statements above and that I have provided true and correct information and all required supporting documents unless otherwise indicated.

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