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APPENDIX B SAMPLE PARTICIPATION FORM North Dakota Department of Public Instruction This form MUST be returned to the school By Parent Name Student s Name Please review the enclosed brochure that provides a brief overview of the supplemental services provision. Please note the list of North Dakota-approved providers. Remember that participation is required* If your child does not attend the assigned services you will forfeit his/her eligibility and services will be offered to another interested family. Check one Yes I am interested in enrolling my child to receive supplemental education services. Please send me more information* No I am not interested in receiving supplemental services for my child. If you checked Yes and your child is identified as eligible you will receive more detailed information on North Dakota s State-Approved Supplemental Service Providers. Would you like the school to contact you to assist you in choosing a provider Yes. Please contact me at the telephone number listed below. No* I plan to choose a provider on my own* Signature of Parent/Guardian Address City Telephone E-mail State Retrieved from the Iowa Department of Education Supplemental Educational Services Provider Selection Form Grade School Academic Year Check the box that applies My son/daughter WILL participate in the Supplemental Educational Services program as it is described in No Child Left Behind* I am selecting the state-approved provider from the list provided to me. 1st choice I select 2nd choice I select I understand that the provider will regularly inform me and my child s teacher s of his/her progress. educational services for all of the students who choose to participate participation will be based on prioritized academic need as defined by the district. of 2001. Date Printed Name of Parent/Guardian Daytime Telephone Number Evening Telephone Number Office Use Only Date Received SES Provider. Remember that participation is required* If your child does not attend the assigned services you will forfeit his/her eligibility and services will be offered to another interested family. Check one Yes I am interested in enrolling my child to receive supplemental education services. Please send me more information* No I am not interested in receiving supplemental services for my child. Check one Yes I am interested in enrolling my child to receive supplemental education services. Please send me more information* No I am not interested in receiving supplemental services for my child. If you checked Yes and your child is identified as eligible you will receive more detailed information on North Dakota s State-Approved Supplemental Service Providers. If you checked Yes and your child is identified as eligible you will receive more detailed information on North Dakota s State-Approved Supplemental Service Providers. Would you like the school to contact you to assist you in choosing a provider Yes. Please contact me at the telephone number listed below. Would you like the school to contact you to assist you in choosing a provider Yes. Please contact me at the telephone number listed below. No* I plan to choose a provider on my own* Signature of Parent/Guardian Address City Telephone E-mail State Retrieved from the Iowa Department of Education Supplemental Educational Services Provider Selection Form Grade School Academic Year Check the box that applies My son/daughter WILL participate in the Supplemental Educational Services program as it is described in No Child Left Behind* I am selecting the state-approved provider from the list provided to me.