Form Isbe 20 81 – Fill Out and Use This PDF

1.

The child(ren) listed on this form moved FROM a residence in

SCHOOL DISTRICT,

CITY,

STATE,

COUNTRY

TO a residence in

SCHOOL DISTRICT,

CITY,

STATE

.

2.

The child(ren) moved (complete both a and b):

a. on own as worker, OR

with the worker, OR

to join or precede the worker.

b. The worker,

FIRST NAME AND LAST NAME OF WORKER

is the child or the child’s

parent

spouse

guardian

i. (Complete if “to join or precede” is checked in 2a.) The worker moved on:

MM/DD/YYYY

. The child(ren) moved on:

MM/DD/YYYY

.

3.

The Qualifying Arrival Date was:

(provide comment)

MM/DD/YYYY

1.

Male Parent/Guardian (Last Name, First Name)

3.

Legal Male Parent/Guardian (Last Name, First Name)

5. Current Address (Street, City, State, Zip)

6. Telephone (Home and Cell)

7. Home Base District/State

(Include Area Code)

2.

Female Parent/Guardian (Last Name, First Name)

4.

Legal Female Parent/Guardian (Last Name, First Name)

D. CHILD/SCHOOL DATA (List all eligible children/youth)

NGS ENROLLMENT

1. Last Name 1/Last Name 2

2. First Name

3. Middle Name

4. Sufix

5. NGS ID

6. Sex

7. Birth Date

8. Code

9. MB

10. Birthplace (City, State, Country)

11. SSID

12. Enroll Date

13.

GR

14. Type

E. PARENT/GUARDIAN/SPOUSE/WORKER SIGNATURE

F. ELIGIBILITY CERTIFICATION

I understand the purpose of this form is to help the State determine if the child(ren)/youth listed on this form is/are eligible for the Title I, Part C, Migrant Education

I certify that based on the information provided to me, which in all relevant aspects is relected above, I am satisied that

Program. To the best of my knowledge, all of the information I provided to the interviewer is true.

these children are migratory children as deined in 20 U.S.C. 6399(2) and implementing regulations, and thus eligible as

I give permission for my child(ren) to participate in the Migrant Education Program.

such for MEP services. I hereby certify that, to the best of my knowledge, the information is true, reliable and valid and I

__________________________________________

_______________________________________________

__________________________________

understand that any false statement provided herein that I have made is subject to ine or imprisonment pursuant to 18

U.S.C. 1001.

Signature

Relationship to the Child(ren)

Date (mm/dd/yyyy)

_____________________________________________________________

__________________

Language Used to Explain the Contents of This Document:

ENGLISH

SPANISH

OTHER (specify): _________________________________

Signature of Interviewer

Recruiter ID

Date (mm/dd/yyyy)

_____________________________________________________________

__________________

Signature of Designated SEA Reviewer

Date (mm/dd/yyyy)

ILLINOIS STATE BOARD OF EDUCATION MIGRANT EDUCATION PROGRAM CERTIFICATE OF ELIGIBILITY

School Year 20 ______ – 20 ______

DISTRICT NAME AND NUMBER/AGENCY

COE# (year and number)

G. CHILD’S ETHNICITY/RACE

RACE

ETHNICITY

(Check one or more, regardless of ethnicity status selected.)

CHILD’S NAME (First and Last)

1- Hispanic/Latino

1-American Indian or

3- Black or

4- Native

(Y/N)

2- Asian

Hawaiian or

5-White

6-For DES Use Only

Alaska Native

African American

Other Paciic

Islander

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

School Year

Residency Veriication

Person Interviewed

Relationship

Source of Veriication

Signature of Person Verifying

Date

Date

(mm/dd/yyyy)

____________________________________________________________________

_______________________________________________

__________________________________

Signature

Relationship to the Child(ren)

Date (mm/dd/yyyy)