Page 1 of 2
AFFIDAVIT OF STUDENT ADMISSION INFORMATION
(FOR PARTICIPANTS IN ADDRESS CONFIDENTIALITY PROGRAM)
NOTICE TO PERSON SIGNING AFFIDAVIT: A person who knowingly falsifies
information on a form required for a student’s enrollment in a public school shall be
liable for tuition or other costs, as provided in Education Code 25.001(h), if the student
is not eligible for enrollment but is enrolled on the basis of false information. In
addition, presenting false information or false records is a criminal offense under
Penal Code 37.10.
1. ____________________________________ seeks admission as a student to the
_____________________ [School District (District)][Open-Enrollment Charter School
(Charter)].
2. My name is ______________________________. My relationship to the student is
_____________________________. The name(s) of the student’s parent(s) or legal
guardian(s) residing in the [District][geographical area of the Charter], if any, are:
_______________________________________________________________________
_______________________________________________________________________
3. The student is [an adult who is enrolled in] [a minor residing with an adult who is enrolled
in] the Texas Attorney General’s Address Confidentiality Program (ACP). A physical
home address will not be provided in writing. However, proof of participation in the ACP
program, including a post office box address for all District or Charter mailings concerning
the student, will be provided to the District or Charter. (Attach copy of participant’s ACP
card.)
4. After consultation with an appropriate District or Charter administrator or designee
regarding enrollment eligibility, I certify that the student is eligible for enrollment in the
district.
5. After consultation with an appropriate District or Charter administrator or designee and
reviewing attendance policies, campus assignment policies, and attendance zones, the
District or Charter representative and I have agreed on an appropriated campus for
placement. I certify that the student is eligible for placement at the designated campus.
6. After reviewing policies and procedures regarding student transportation with an
appropriate District or Charter administrator or designee, I certify that the student is
eligible for ridership on a district bus route for the designated campus. (An administrator
will verbally instruct the student’s bus driver as to the appropriate bus stop for the
student.)
7. The student [is] [is not] currently under an order for placement in an alternative education
program or under an expulsion order. (Attach a copy of the order. If a copy is not
available, provide information regarding the basis for the order and the terms of the
order.)
______________________________________________________________________
______________________________________________________________________
