Parents: Please complete and return to your child’s teacher or the school reception desk immediately. You may ask for assistance in making your tutoring choice. If you are not interested in the free tutoring, please check (ü) at the bottom of this form and sign your name.

(Please Print)

Child’s Name: _____________________________________ Date: _________________

School: _________________________ Teacher: __________________ Grade: _____

ESE: Yes _______ No ________ ESOL: Yes __ No _____ Language:

Parent/Guardian: _________________________________________________________

Address: ________________________________________________________________

Phone: ________________________________ Cell Phone: _______________________

The school will determine if my child is eligible. If my child is eligible, I am aware that my child will receive SES, which is after school tutorial services, from the state approved provider I selected. Title I will pay up to $1282 for these services for the school year. This form can be submitted immediately but must be submitted by me no later than September 19. Tutoring will begin by October 15.

My first Tutoring Service Provider choice is: ________________________________________

My second Tutoring Service Provider choice (if needed) is: _____________________________

My third Tutoring Service Provider choice (if needed) is: _______________________________

______________ I am not interested in Supplemental Educational Services (SES) at this time.

Parent Release Statement

Completion of this form gives permission for Orange County Public Schools to release my address and telephone number and my child’s test scores, IEP and other academic information as needed to only the 2007-2008 selected provider(s) above. The selected provider(s) will only contact me to finalize SES arrangements. All other SES communications should be handled by the SES Senior Administrator.

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Parent/Guardian’s Signature Date Signed