REQUEST FORM FOR

DISTRICT SECONDARY GUIDANCE/COUNSELING SERVICES

TEXTBOOKS, STANDARDIZED TESTS, AND INDIVIDUAL INSTRUCTIONAL MATERIALS

DISTRICT PUPIL HEALTH SERVICES

These services must be requested by, or on behalf of, the pupil no later than SEPTEMBER 15, 2017.

School Year Ending May 2018

Please indicate, by placing an “X” in the appropriate box below, whether or not you request these items this school year.

( I Do is already checked for you which allows our school to receive state aid $$ for these services)

Please fill in your Child’s Name and grade and sign below.

The State of Minnesota has authorized local public school districts to allow pupils

attending a nonpublic school, (includes home schools), established and operating within the school district boundaries, access to the existing district Secondary Pupil Guidance of,

and Counseling Services program.

Pupil’s Name:_______________________________________________________ Grade Level:___________

                                                                Please Print Students Name

Name of School:     St. Wenceslaus School      

X I do request that the district’s Secondary Pupil Guidance and Counseling

          Services program (Grade 7 & 8) be made available to the above pupil this school year.

 I do not wish to request Secondary Pupil Guidance and Counseling Services this year.

The State of Minnesota has authorized local public school districts to allow pupils

attending a nonpublic school, (includes home schools), established and operating within the school district boundaries, access to the existing district Pupil Health Services Program.

X I do request that the district’s Pupil Health Services program be made available to the above pupil this school year.

 I do not wish to request Pupil Health Services this school year.

The State of Minnesota has authorized local public school districts to loan textbooks, standardized tests, and individualized instructional materials to pupils attending a nonpublic school, (includes home schools), established and operating within the school district boundaries.  These materials must be secular in nature, designed primarily for individual use by the pupil in a particular class or program in the school the pupil regularly attends.

X I do request that textbooks, standardized tests, and individualized instruction materials be provided on loan to the above pupil this school year.

 I do not wish to request the loan of any materials this school year.

Verification of Use: I hereby verify that the textbooks and individualized instructional material requested are to be used by the pupil named above in a course instruction in that pupil’s elementary or secondary school.

____________________________________________________________                      ________________________________________                  

Signature of Pupil, Parent, or Guardian                                                         Date

PLEASE RETURN SIGNED FORM TO ST. WENCESLAUS SCHOOL BY SEPTEMBER 15, 2017.

SWS State Funding 2017