SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

MIGRANT PROGRAM SERVICE

20__-20__

PLEASE PRINT LEGIBLY IN BLACK INK

Dear Parents,

XYZ Charter is helping the state of Texas identify students who may qualify for migrant program services that provide extra help in academics.

Please answer the following questions and return this form to the school.

Please list the ages and names of children enrolled in XYZ Charter:

Age:_____Name (Last, First, M.I.) _______________________________________________

Age:_____Name (Last, First, M.I.) _______________________________________________

Age:_____Name (Last, First, M.I.) _______________________________________________

Age:_____Name (Last, First, M.I.) _______________________________________________

1. Has your family moved any time during the last three years from one school district to another in Texas or to another state? ___Yes ___No

2. Were any of these moves made to find temporary or seasonal work in agriculture

related to packing, processing, harvesting, cultivating of crops, food procession, dairy

work, forestry, fishing, etc.? ___Yes ___No

If you answered “Yes” to question 2, please complete the following information:

Name of Parent/Guardian_______________________________________________________

Address:____________________________________________________________________

Telephone:__________________________________________________________________

Please list the names and ages of children who are not enrolled in school:

Age: _____Name (Last, First, M.I.) ______________________________________________

Age: _____Name (Last, First, M.I.) ______________________________________________

Age: _____Name (Last, First, M.I.) ______________________________________________

Age: _____Name (Last, First, M.I.) ______________________________________________

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