Texas A&M AgriLife Extension Service

Verification of Eligibility and/or Request for Absence Form Hays County 4-H Horse Point Show This information is requested in accordance with the requirements of Senate Bill 1 and in cooperation with the Texas Education Agency and local public school board policies. This form serves as the official school notification of the 4-H member's intent to participate in one or more extra-curricular activities representing 4-H.

Parent/Guardian/County Extension Agent - Complete This Section [Parent must complete - in Principal’s section - name of activity, date/s of activity, specific date/s requested for absence from school for each activity.] In accordance with 4H policy, provided by our local Extension Office, I respectfully request (check (T)one): ( ) Academic eligibility information only. (My child will not miss any school class time.) My child is in the

grade at

(name of school) in the

I.S.D.

Signature of Parent/Guardian:

I hereby certify that is a member of 4-H in Hays County and is scheduled to participate in the activity/ies listed below representing 4-H. He/She will be under the supervision of a Texas A&M AgriLife Extension Service faculty or agency's designated volunteer leader. Date

County Extension Agent Signature

Principal - Complete This Section Check (T) one: ( ) I do certify the student is academically eligible to participate in the extracurricular activity/ies listed and approve his/her request as indicated below. ( ) I do not certify the student because he/she is NOT academically eligible to participate in the extracurricular activity/ies listed below. Grading Period upon which eligibility is being determined is: 4-H Activity/Date Hays Co. 4-H Horse Show Jan 6, 2018

Date/s Requested To Miss School N/A

Signed: (by Principal or other school representative)

Starting Date:

Excused Absence Grante d [ ] [ ] [ ] Title

Excused Absence NOT Granted [ ] [ ] [ ]

Ending Date: Does Not Apply XX [ ] [ ] Date:

Complete one form per grading period. 4-H member return form to the Extension Office by deadline. Schools make copy for their records as required. 01/08