Educational Services Program TITLE I-PARENT CONSENT
DATE:
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Month
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Day
Year
Date
School District: Duval County
School Year: 2026-2027
Student:
School:
Date of Birth:
Principal:
2026-27 Grade:
Teacher:
Reason for Referral:
Reading
Math
To Parents:
Your child is eligible to receive Title I services in the area(s) checked above from the sending school district. These services will be provided by a Third Party Contractor or qualified instructional personnel and will be paid for by the sending school district using Federal Title I, Part A grant funds.
In order to assess your child's needs, an evaluation will be provided. This may include a review of standardized test scores, informal testing and interviews with school personnel to assure your child receives the appropriate educational program. Student progress reports will be made available to you and your child's teachers during the school year. Your feedback is also welcomed.
At the end of the year, your child will be assessed. This test may be administered to your child even if he/she is no longer receiving services at the time of testing. Our goal for your child is to see growth when comparing the pre & post test.
Before these services can begin, we must have your consent. This may be given by signing in the space below.
(Please Select one)I GIVE MY PERMISSION FOR MY CHILD TO RECEIVE TITLE I LEARNING.
Signature of Parent or Guardian
Date
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Month
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Day
Year
Date
Please Print Parent or Guardian Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I DO NOT GIVE MY PERMISSION FOR MY CHILD TO RECEIVE TITLE I LEARNING.
Signature of Parent or Guardian
Date
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Month
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Day
Year
Date
PLEASE RETURN THIS FORM TO YOUR CHILD'S CLASSROOM TEACHER
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Duval County Public Schools - Title I Private Schools ProgramReferral for School Year 2026-2027
Private School:
Classroom Teacher:
Student Name:
Parent Phone Number:
Format: (000) 000-0000.
Grade in 2025-2026 school year:
Date of Birth:
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Month
-
Day
Year
Date
Gender:
Male
Female
Ethnicity:
Black
White
Hispanic
Asian
Pacific Islander
American Indian
Multiracial
Student Address:
City:
State:
Zip:
Public School Attendance Area:
Please choose the subject areas being requested for grades K-12
Reading & Math
Reading Only
Math Only
Reading Skills
Reading Skills options
Reads Poorly
Does not recognize high frequency words
Seldom self-corrects
Cannot sustain reading behaviors alone
Does not use meaning of story to predict
Does not recognize phonemic blends
Trouble recalling/summarizing text
Below average comprehension
Math Skills
Math Skills options
Does not know basic math facts
Has difficulty with number relationships
Difficulty naming geometric shapes
Does not understand fractional values
Cannot count by 2's, 4's, and 10's to 100
Cannot tell time on a standard clock
Does not recognize patterns
Cannot identify operation for word problems
Academic Skills
Academic Skills options
Has difficulty following simple directions
Has poor reasoning abilities
Cannot work independently
Has poor retention skills
Little or no listening comprehension skills
Poor organizational skills
Poor time management skills
Does not ask for assistance
Current Student Record Data Check all that apply.
Current Student Record Data options
Repeating current grade
Non-retained but overage
Unsatisfactory progress report card
Difficulty maintaining grade-level progress
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