Summer School Packet Middle, Junior High, High School

Transcripción

1 DATE: FAX: ATTN: Summer School Program Coordinator 555 Hemphill Street, Suite 200 Fort Worth, Texas p f gillchildrens.org Summer School Packet Middle, Junior High, High School PAGES: 11 Enclosed is a packet of information for Gill s summer school assistance program, which contains the following: Information Sheet- for students and parents Referral Form- for school personnel Gill Application- for students and parents **THIS COVER LETTER AND ALL THREE ITEMS NEED TO BE DISTRIBUTED TO ANY TEACHERS, COUNSELORS, OR OTHER SCHOOL PERSONNEL WHO ARE WORKING WITH STUDENTS WHO NEED TO ATTEND SUMMER SCHOOL. You can make as many copies of these as you need. Please read the parent s information sheet so that you will be aware of how and when students can seek our assistance. Please do NOT refer parents to Gill once registration has begun. We will accept applications until the day before registration. For each student referred to Gill: Parents will need: Information Sheet Application Income verification Student s most recent transcript or report card. Teachers, Counselor, Principal, or Vice Principal will need: To complete the Referral Form and fax it to Gill or return it to the parents so they can submit along with their application. If you have any questions, please feel free to contact me at , ext. 101, Monday Friday, 8:30 am to 3:30 pm. Thank you for your cooperation, Maria D. Trevino Senior Case Manager mtrevino@gillchildrens.org

2 GILL CHILDREN S SERVICES, INC. Middle, Junior High and High School Summer Session Information A student who must attend summer school, but whose family is financially unable to afford the whole tuition fee, may be eligible for tuition assistance through Gill Children s Services if he/she is not eligible for any other program. GILL WILL ACCEPT APPLICATIONS FOR STUDENTS, 18 and under: WHO LIVE IN TARRANT COUNTY AND HAVE EXHAUSTED ALL OTHER POSSIBLE RESOURCES (all other avenues must be pursued first before turning to Gill). WHO FAILED TO GAIN THE SKILLS NECESSARY TO ADVANCE TO THE NEXT GRADE (i.e. Gill will not assist if the child had excessive absences due to truancy and/or disciplinary problems.) At a maximum- Gill will only assist with two courses. WHO HAVE GOOD ATTENDANCE AND CITIZENSHIP RECORDS. WHO HAVE NOT PREVIOUSLY BEEN ASSISTED WITH SUMMER SCHOOL TUITION BY GILL. TO APPLY, THE FOLLOWING IS NEEDED: A Gill application completed by the parent/guardian. A referral form completed by the student s teacher, counselor, or principal (which they may send to us directly). Verification of family income. Copies of the student s transcript and or current report card. Mail or fax this information to Gill offices. The family can contact us to verify we have received their student s application. Families may be asked to contribute to the cost of summer school where appropriate. GILL CHILDREN S SERVICES, INC. 555 Hemphill Street, Suite 200 Fort Worth, Texas Fax **Send the application and information early to insure time to process the application. Applications will not be processed once registration has begun.

3 SUMMER SCHOOL TUITION ASSISTANCE PROGRAM REFERRAL FORM Form to be filled out by Counselor, Teacher or Principal (or VP) and returned to: Gill Children s Services, Inc. 555 Hemphill Street, Suite 200 Fort Worth, Texas Fax Phone I am recommending for tuition assistance from Gill Children s Services for the summer session 20. This student must attend summer school this summer for the following reason(s) (LIST ALL FAILED CLASSES): If high school student, does this student have the option to drop electives next year to make up the failed classes? N/A Yes No- If no, please explain: List classes that the student must take this summer: Price of each class: $ # of Classes Registration fee (if any) $ Total $ This student will be promoted if he/she successfully completes this summer session. No Yes This student s attendance has caused the failure. No Yes # of absences Does child receive free or reduced lunch? No Yes Was there extenuating circumstances that caused the failure(s)? : Is this student motivated? No Yes Comments: Has there been parental involvement during the school year? No Yes Additional Comments: Print Name: Position: School: Phone: Summer School Registration Date: 1 st Day of Summer School:

4 Summer School Site: District: children s services, inc. 555 Hemphill Street, Suite 200 Fort Worth, Texas p f Date Received: Application for Financial Assistance Child s Last Name, First Middle Age Date of Birth Sex Race If you would like your voucher ed, list your address: 3. Social Security # 4. Phone 5. Residence: Number Street City State Zip How long has the child lived in Tarrant County? 6a. Mother s Name Age Social Security # Marital Status 6b. Father s Name Age Social Security # Marital Status 6c. Other Legal Guardian Age Social Security # Marital Status (i.e. Grandparent, Step-Parent) Does a parent live at a different address than the child? Which parent? (Circle one:) Mother Father Number Street City State Zip 7. Who has legal custody of the child? 8. Nearest relative or friend? Name /Relationship Phone # 9. What language(s) do the parents speak? 10. What school is the child attending? Name Phone # 11. What services, supplies or equipment are you requesting for this child? 12. Why does the child need the services, supplies or equipment (describe health or other problems of child)?

5 13. Who prescribed, or told you that your child needed, the services, supplies or equipment? Name Phone # Address: 14. Who will provide the services requested? (give name, address & phone # of each provider): 15. How much will each service or supply cost? How much of this cost are you requesting as assistance from Gill? Who will pay the difference between the total cost and the amount you are requesting from Gill? 16. Have you received assistance from Gill before? No Yes Date 17. How did you hear about Gill Children s Services? 18. List other community agencies or resources where you asked for help before applying to Gill. What was their answer? Agency: Answer: 19. Give name, address and phone number of a person we may contact as a reference on this request (Minister, DHS or Hospital Caseworker, etc.). 20. Where do the parents work? Father s Employer Address Phone Monthly Take-home Mother s Employer Address Phone Monthly Take-home

6 Step-parent s Employer (with whom child is living) Phone Monthly Take-home Please attach proofs of income for mother, father and/or legal guardian: two most recent paycheck stubs, most recent income tax return, or a letter from the employer. 21. Please list ALL other adults and children who are living at the same residence as this child. You may also list additional children you are applying for here: Name Kinship to child Age DOB 22. Please list the family' s monthly obligations: Monthly Payment Rent/Mortgage Payment Electric Gas Water Food/Groceries Home Phone Cell Phone/Pager Car Payment Car Gas Car Insurance Child Care Health Insurance Hygiene/Personal Expenses Major Credit Cards (Total Balance ) Loans (Total Balance ) Medical Bills Other (Please specify) Other (Please specify) Other (Please specify)

7 Other (Please specify) *Gill evaluates each request individually and will ask for verification of expenses if income and expenses do not match up. 23. Does the parent/guardian receive any of the following? Child Support? No Yes Amount TANF No Yes Amount Housing No Yes WIC No Yes Social Security: Retirement or SSI/SSD? No Yes Amount Who is receiving this amount? Food Stamps No Yes Amount 24. Is this child covered by any insurance policy or program (including Medicaid)? Yes No Which insurance company? (circle) Medical Dental Policy number Is this through parent s place of employment? Yes No Which parent? 25. Please comment on any financial obligations, other than usual living expenses, or any other hardships such as medical bills or outstanding debts that may hinder your ability to pay for the needed services yourself. 26. I acknowledge that Gill Children s Services, Inc. will rely on the information on this application in making its decision on this request. I authorize Gill to consult with, or release information to any person whom they deem necessary to verify this information and the request. I understand it is sometimes necessary for Gill to do this in order to make its decision on my request. This authorization expires one year from the date below. Signature: Parent or Guardian Date: 27. If someone other than the person signing #26 filled out this application, please give us the following information: Name: Relationship to child:

8 Address: Phone: Agency and/or Title: children s services, inc. 555 Hemphill Street, Suite 200 Fort Worth, Texas p f Date Received: Aplicación para Ayuda Financiera Appellido del Nino Primer Otro Edad Fecha de Nacimiento Sexo *Otros ninos aputne en pagina 3, # Seguro Social 4. Telefono 5. Direccion: Numero Calle Ciudad Estado #Postal Cuanto tiempo tiene el nino de vivir en el Contado de Tarrant? 6a. Nombre de Madre Edad Seguro Social Estado Civil 6b. Nombre de Padre Edad Seguro Social Estado Civil 6c. Otra persona con quien vive el nino Edad Seguro Social Estado Civil (i.e. padrastros, abuelos) Direccion de la Madre o Padre si es diferente del nino. Madre o Padre? Numero Calle Ciudad Estado #Postal 7. Quien tiene custodia legal de el nino? 8. Telefono de pariente/vecino/amistad de la familia? Nombre Telefono 9. Los padres hablan ingles? 10. Que escuela atende su nino?

9 Nombre Telefono 11. Que servicios, aparatos o materiales esta pidendo para su nino? 12. Porque necisita el nino estos servicios, aparatos, o materiales? 13. De informacion sobre el professional que prescribo el servicio, aparatos o materiales? Nombre Telefono Direcion 14. Quien va proveer el servicio que usted pide (nombre, telefono, direccion)?: 15. Cual es el costo de el servicio o materiales? Cuanto es la asistencia financiera que usted pide de Gill? Quien pagara la diferencia de el costo total que usted pide de Gill? 16. Ha recibido asistencia de Gill en el pasado? No Si Fecha 17. Como vino usted saber de Gill Children s Services? 18. Lista de otras agencias de la comunidad con quien usted hizo contacto antes de hacer aplicacion con Gill y la respuesta? Agencia: Respuesta: 19. De el nombre, direccion y telefono de la persona que podemos contactar como referencia acerca de esta solisitud. 20. Donde trabajan los padres? Empleo de Padre Direccion Telefono Ganancia Mensual Empeo de Madre Direccion Telefono Ganancia Mensual

10 Empleo de Madrastra/Padrastro Direccion Telefono Ganancia Mensual Favor de incluir prueba de ingresos de la madre, el padre o padrastros: Dos mas recientes cheques, carta del mayordomo o copia de su declaracion de impuestos sobre rentas (income tax). 21. Otros ninos y adultos que viven en su hogar: Nombre Relacion al nino de pagina 1 Edad Fecha de Nacimiento Ingresos 22. Obligaciones Financieras por mes: Pago por mes Renta Luz Gas Agua Comida Telefono de Casa Telefono Celular Pago de Carro Gasolina de Carro Aseguransa de Carro Cuidar de Ninos Aseguransa de Salud Personal/Compras de Casa Tarjetas de Credito (Balance Total $ )

11 Emprestitos (Balance Total ) Cuentas Medicos Otro (Especifica) Otro (Especifica) Otro (Especifica) Otro (Espicifica) *Gill tiene el derecho de pedir prueba de sus obligaciones financieras por mes. 23. Tienen los padres/guardian otros ingresos o soporte financiero? Soporte de Nino? No Si Cantidad TANF? No Si Cantidad Casa de Gobierno? No Si WIC? No Si Seguro Social: Retiro o Desabilidad? No Si Cantidad Quien recibe el Seguro? Estampillas de comida? No Si Cantidad 24. El nino tiene aseguramiento medico (incluyendo Medicaid)? Si No Compania de Aseguramiento? (circle) Medica Dental Numero de poliza De cual padre? La poliza es un plan de grupo en su lugar de empleo? Si No 25. Por favor de comentar sobre otras obligaciones o dificultades financieras que pueden impedir su habilidad de pagar por estos servicios usted mismo. 26. Yo reconozco que Gill depende de la informacion en esta aplicacion para ser la decision en este pedido. Yo autorizo que Gill consulte con, o de informacion a cualquier persona que ellos crean necesario para verificar esta informacion y pedido. Yo comprendo que es necesario que Gill haga esto para poder ser la decision en este pedido. Esta autorizacion se expirara dentro de un ano de esta fecha. Signatura: Padre o Guardian Fecha:

12 27. Si otra persona en vez de la persona quien firmo #26 lleno esta aplicacion, por favor de dar la informacion siguiente: Nombre: Relacion al Nino de pagina 1: Direccion: Telefono: Agencia y/o Titulo: