Student Eligibility Worksheet

STUDENT ELIGIBILITY WORKSHEET

This worksheet collects information necessary to determine a student's eligibility for admission, placement, program services, or financial assistance. Completion of this form authorizes the institution to verify submitted documentation and to request records as needed to substantiate eligibility. Submission of false information may result in denial of services, withdrawal of admission, or other administrative action.

Student Information

Parent / Guardian (if student is minor)

If student is under the age of majority, a parent or legal guardian must complete and sign this section. If student is an adult, the student should complete signing information in the signature block.

Program Application Details

Eligibility Criteria Checklist

Indicate whether the student currently meets each criterion. Documentation supporting affirmative responses must be submitted with this worksheet.

Residency: Student resides within the jurisdiction or service area.

Age Requirement: Student meets age requirement for the program.

Grade / Placement: Student meets grade or placement requirement for program.

Academic Standing (GPA): Meets minimum GPA requirement. Current GPA:

Attendance: Attendance record meets program standards.

Immunizations / Medical Clearance: Required immunizations or medical forms are on file.

IEP / 504 Plan: IEP or 504 Plan in effect and on record (if applicable).

Disciplinary Status: No current disciplinary restrictions preventing participation.

Documentation Checklist

Check all documents included with this worksheet. If a document is not available, indicate expected date of submission.

Birth certificate / government ID

Proof of residency (utility bill, lease, etc.)

Official transcripts / report cards

Immunization / medical records

IEP / 504 documentation (if applicable)

Medical / Emergency Information

Financial Aid / Payment Information (if applicable)

I request consideration for financial assistance, fee waiver, or scholarship. I understand additional verification of income and family size will be required.

Certifications, Consent, and Authorization

By signing below, I certify that all information provided on this worksheet and any attachments is true, accurate, and complete to the best of my knowledge. I understand that falsification or omission of material facts may result in denial of services, withdrawal of enrollment, or other disciplinary or legal action. I authorize the institution to obtain and verify records, including but not limited to school transcripts, immunization records, residency documentation, and relevant medical or special education records, from third parties as necessary to determine eligibility.

I further authorize release of information between prior or current educational institutions, health care providers, and the reviewing institution for the sole purpose of verifying eligibility for program admission or services. I understand that information obtained will be kept confidential in accordance with applicable laws and institutional policy, except as required by law or with my further written authorization.

I understand that completion of this worksheet does not guarantee eligibility or admission and that final determination will be made by authorized personnel following review of all required documentation.

I certify under penalty of perjury that the information provided is true and correct.

I consent to the verification and release of records as described above for the purpose of eligibility determination.

Administrative Use Only

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