Selma Unified MS Supplemental Educational Services/

Servicios Educativos Suplementarios 2015-2016 Request for SES Services/Petición para Servicios SES Student Name______________________________________________ School______________________________ Home Address_____________________________________________

Telephone__________________________

Parent Name_______________________________________________ Grade:______________________________ I would like to request SES services. My top two choices are: 1. ________________________________

2._____________________________________

I understand that eligibility is prioritized for students who are not proficient or advanced on state/local assessments and for families that qualify for the Free and Reduced Lunch Program.

Parent Signature___________________________________ Date_________________ Parent Initials____________ ********************************************************************************************

Nombre del Alumno_____________________________________________ Escuela____________________________ Dirección________________________________________________________ Teléfono___________________________ Nombre de Padre________________________________________________ Grado_____________________________ Deseo pedir servicios de SES. Los dos proveedores de mi gusto son: 1. ________________________________

2. ________________________________

Yo entiendo que la elegibilidad será priorizada a alumnos que no son proficientes o avanzados en exámenes estatales o locales y para familias que califican para el programa de Almuerzo Gratis o Reducido. . Firma de Padres____________________________________ Fecha_________________ Iniciales____________ TURN IN TO THE TABLE OUTSIDE TONIGHT! / ¡ENTREGUE A LA MESA AFUERA ESTA NOCHE! Form is due no later than November 9, 2015 4:00 pm / Formulario se debe a más tardar el 9 de noviembre 2015 a las 4 pm School Use Only: Form received from: Student Eligibility:

□parent □Yes

on ___________________________________. □No