Canales-Molina Maria 3519024 2777985

Student
Information
First Name Middle Name Last Name

Maria Guadalupe Canales Molina
Student Lives With Date of Birth Gender

MO, FP 10/04/2006 Female
Male
Enrollment Information
Current Grade
Ninth Grade
Grade entering next school year

Tenth Grade
School entering next school year

KIPP Sunnyside High School
Enrollment Information
Home Address 2918 Trail Lake Dr
Apartment, Unit, or Suite Number
State City Zipcode

TX Houston 77045
Mailing Address Information
Mailing Address 2918 Trail Lake
Mailing State Mailing City Zipcode

TX Houston 77045
Guardians Information
Relationship to First Name Last Name

Student María Canales
MO
Contact Information
Home Phone Work Phone Mobile Phone

Number Number Number
8323887132 8323887132 8323887132
Email Address canalesnathaly8@gmail.com
Guardian Address Information
Address Street 1 2918 Trail Lake Drive
State City Zipcode Relationship to

TX Houston 77045 Student
FA
First Name Last Name
Juan Canales
Page 1 of 30
Contact Information

7137540386
Address Street 1 2918 Trail Lake Drive

MO
Maria Marleny Canales
Contact Information

8323887132
Address Street 1 2918 Trl Lk Dr

MO
Elsa Marina Canales
Contact Information

8324107539 8324107539
Address Street 1 3302 Dalmatian Dr

CT
Carlos Posada
Contact Information

8327053939
Page 2 of 30
Email Address
Address Street 1 3302 Dalmatian Dr

MO
Mari Marleny Canales
Contact Information

8323887132 8323887132 8323887132
Address Street 1 2918 Trail Lake Lane
State City Zipcode

TX Houston 77045
Page 3 of 30
PARENT/GUARDIAN INFORMATION
This section is to update your family information. Please follow these

important instructions:
In "Address Street 1" you should write out the building number and
street name.
In "Address Street 2" you should write any apartment, suite, or unit
number.
If you only have one phone number, please list it once below.
Emergency contacts should not be either of the guardians listed
below.
Guardian First Name Guardian Last Name Guardian Mobile Phone Number
María Canales 832-388-7132
Guardian Email Guardian Home Phone Number Guardian Work Phone Number
canalesnathaly8@gmail.com 832-388-7132 832-388-7132
Guardian Address Street1 Guardian Address Street2 Guardian Address City

2918 Trail Lake Drive Houston
Guardian Address State Guardian Address Zipcode Guardian Relationship to Student

TX 77045 MO
Guardian Education Level Guardian 2 First Name Guardian 2 Last Name

DS Juan Canales
Guardian 2 Mobile Phone Number Guardian 2 Email Guardian 2 Home Phone Number
713-754-0386 canalesnathaly8@gmail.com
Guardian 2 Work Phone Number
Guardian 2 Address Street1 Guardian 2 Address Street2 Guardian 2 Address City

Guardian 2 Address State Guardian 2 Address Zipcode Guardian 2 Relationship to

TX 77045 Student
FA
Guardian 2 Education Level

DS
Do you need to update the guardian ID on file?

Yes No
(For example Passport, driver's license, or government-issued ID with photo.)
If we do not have a current valid form of ID please upload a copy
(For example: Passport, driver's license, or government issued ID with photo.)
No Attachment Available
Who has legal custody of the

child?
Both
Emergency Contact Information
Page 4 of 30
Please provide at least one emergency contact. Note that we will only contact the individual(s) listed below should we not be
able to contact either Parent/Guardian.
The adults listed below as emergency contacts cannot be either of

the parents or guardians listed above!
Emergency Contact 1 First Name Emergency Contact 1 Last Name Emergency Contact 1 Mobile
Lorena Canales Number
832-705-3453
Emergency Contact 1 Home Emergency Contact 1 Email Emergency Contact 1

Number canalesnathaly8@gmail.com Relationship
CO
Emergency Contact 1
This individual should be contacted in a medical emergency

Yes No
This individual has permission to transport

Yes No
Would you like to add a SECOND Emergency Contact?

Yes No
This emergency contact cannot be either of the parents or guardians listed

above!
Guadalupe Canales Number
832-858-1018

Number canalesnathaly8@gmail.com Relationship
AU
Emergency Contact 2

Yes No

Yes No
Would you like to add a THIRD Emergency Contact?

Yes No
This emergency contact cannot be either of the parents or guardians listed

above!
N/A N/A Number
N/A
Page 5 of 30
Number N/A Relationship
N/A N/A
Emergency Contact 3

N/A

N/A
Physician Name Physician Phone Number Hospital Preference
The information asked above is needed as a permanent school record of your child and will be used by school
personnel. This is to certify the above information is correct. I the undersigned do hereby authorize officials of this
school to contact directly the person named on this form and do authorize the above named physician to render such
treatments as may be deemed necessary in an emergency for the health of said child. In the event physician other
persons named on this form or parents cannot be contacted the school officials are hereby authorized to take
whatever action necessary in their judgment for the health of the aforesaid child. I will not hold the school district
financially responsible for the emergency care and/or transportation for said child.
Initial
MC
SIBLING INFORMATION
Siblings
In order to help us eliminate unnecessary notifications please list all students Including the student being registered
on this page. (Each sibling's information entered below will repeat as you fill out other student registrations.)
NOTE: You will still need to fill out separate registration forms for each student who is attending KIPP Texas schools.
How many students (not including this student) will attend KIPP Schools in 2022-2023?
2
Sibling 1 Last Name Sibling 1 First Name

Canales Juan
Sibling 1 Grade Sibling 1 School

4 KIPP Zenith Academy

Canales Nathaly

7 KIPP Spirit College Prep

N/A N/A
Page 6 of 30
N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A
MILITARY CONNECTED INFORMATION

The State of Texas requires schools to collect data relating to the enrollment of military-connected and foster care
students. This collection allows schools to recognize and mentor critical elements of student success for children
who are dependents of military personnel or foster care.
Select one for each question to indicate if your child is a dependent of the following.
Military Connected
Armed forces or reserved forces of the United States (Army Navy. Air Force Marine Corps or Coast
Guard) or Texas National Guard who has been injured or killed while serving on active duty Active
Duty - Amy Navy. Air Force Marine Corps Coast Guard or Texas National Guard Reserve Duty -
Army Navy Air Force Marine Corps or Coast Guard This DOES NOT apply to my child
FOSTER CARE
My student receives Foster Care Services This DOES NOT apply to my child
Please upload Form 2058FC and any additional Foster Care Services court documents
Household Income Survey
KIPP Texas is required to collect and report the socioeconomic status of each student to the Texas Education
Agency for purposes of the annual state accountability ratings and for federal reporting. Please note that this form is
not sent to the Texas Education Agency and that the income levels indicated for your family are not reported to the
Texas Education Agency. Only the Economic Disadvantaged status of each student as determined by the information
provided is reported to the Texas Education Agency.
Do you receive Temporary Assistance to Needy Families (TANF)?

Yes No
Page 7 of 30
Do you receive Supplemental Nutrition Assistance (SNAP)?
Yes No
Please enter your SNAP Number

N/A
How many members are in the household (include all adults and children)?
5
INCOME BEFORE DEDUCTIONS OF ALL HOUSEHOLD MEMBERS (check one box below): Include wages, salary,
welfare payments, child support, alimony, pensions, Social Security, worker’s compensation, unemployment and all
other sources of income (before any type of deductions)
How frequently are you paid?

Bi-Weekly (i.e. every other Friday)
Please enter the closest amount you receive Please enter the closest amount you receive Bi-
WEEKLY: Weekly:
N/A 900
Please enter the closest amount you receive TWICE A MONTH

N/A
Please enter the closest amount you receive Please enter the closest amount you receive Yearly:
MONTHLY: N/A
N/A
Check this box if you choose not to provide income information. The school’s disbursement of federal funds
and accountability rating may be affected by your choice.
N/A
I certify that all the information on this form is true and that all income is reported. I understand the school will
receive federal funds and will be rated for accountability based on the information I provide.
Initials
MC
Page 8 of 30
Student First Name Student Last Name Student Middle Name
Maria Canales Molina Guadalupe
Gen (Jr. Sr. I II) Student Birth Date Student Gender

10/04/2006 F
Student Next Grade Level

10
STUDENT RESIDENCY
Student Address Street1 Student Address Street2

2918 Trail lake
Student Address City
Houston
Student Address State Student Address Zip code

TX 77045
Is mailing address the same as the physical Address?

Yes No
Student Mailing Address Street1 Student Mailing Address Street2

N/A N/A
Student Mailing Address City Student Mailing Address State Student Mailing Address Zip
N/A N/A code
N/A
Have you moved in the last 12 months?

Yes No
Please upload a new copy of a current Proof of Residence
(i.e. current electric bill, current water bill, current gas bill, lease agreement) No cell phone bills.
Is the Student Hispanic?

Yes No
What is the person's race?

American Indian or Alaska Native Asian Black or African American Native Hawaiian or
Other Pacific Islander White
Page 9 of 30
Health History
Student Information
Student First Name Student Last Name

Maria Canales Molina
Student Birth Date Student Next Grade Level

10/04/2006 10
Guardian Information
Your child's health history will help us assess any physical conditions which may require adjusting the school
program. The health information you record on this form will become a part of your child's school health record and
will remain confidential.
Does your child wear any of the following?:

Wears Glasses Hearing Aids N/A
Life Threatening allergies
Does your child have any life threatening allergies?

No
Does your child have any allergies to one or more of the following:
N/A
Please indicate which food allergy your student has

N/A
Please specify the selected allergy.

N/A
(e.g., peanuts bees penicillin)
Do any of these allergies require an EPI-PEN?

N/A
Does your child have any of the following medical conditions:
Page 10 of 30
Asthma
Yes No
Seizure Disorder (Epilepsy)

Yes No
Diabetes
Yes No
Diabetes Type
N/A
Autism
Yes No
Behavior
Yes No
Cancer
Yes No
Cerebral Palsy
Yes No
Obesity
Yes No
Scoliosis
Yes No
Sickle Cell
Yes No
Heart Condition
Yes No
Other health conditions not yet asked

Yes No
What kind of condition and treatment?

N/A
Medication
In the event a student must take medication during school hours, in accordance with our KTX Medication Policy, the
following restrictions apply to the taking of medicine by students while at school:
1. Parent/and or Guardian must complete a Medication Administration form for their child to
receive medication at school.
2. All prescription and non-prescription medicine (including all medication supplies) must to be
Page 11 of 30
supplied by the parent/guardian.
3. Medicine must be delivered to and picked up from school by parent/guardian or other
responsible adult. All medicine to be given during the school day will remain in a designated
locked area in the school.
4. All prescription and non-prescription medicine must be in the original container. The original
container for prescription medication must have the appropriate pharmacy label for your
child.
5. If any medication needs to be administered daily for more than 10 days, consecutively, the
Physician Medication Request form form must be completed and signed by your child’s
physician. (fax/email is accepted)
6. We encourage families only to provide medications to the schools that are medically
necessary.
Please let us know:
Does your child take any medications routinely?

Yes No
List medications and how often taken.

N/A
Will your child require medication administration at school?

Yes No
Does your child have any physical restrictions?

Yes No
What kind and what treatment is needed?

N/A
Does your child have health insurance?

Yes No
What kind of health insurance?

Medicaid CHIP Private Insurance Other
Please tell us your Health Insurance provider's name
Has your student received any new immunizations in the past 12 months?
Yes No
By signing below you attest that the information provided above is accurate and true.
Parent or Guardian Signature
Today's Date
01/10/2022
Page 12 of 30
PARENT/GUARDIAN INFORMATION


TX 77045 MO
Guardian 2 First Name Guardian 2 Last Name Guardian 2 Mobile Phone Number
Juan Canales 713-754-0386
Guardian 2 Email Guardian 2 Home Phone Number Guardian 2 Work Phone Number
canalesnathaly8@gmail.com
Guardian 2 Address Street1 Guardian 2 Address Street2
2918 Trail Lake Drive
Guardian 2 Address City
Houston

TX 77045 Student
FA
Who has legal custody of the child?

Both
Student First Name Student Middle Name Student Last Name

Student Next Grade Level Student Birth Date

10 10/04/2006
MCKINNEY-VENTO INFORMATION
This questionnaire is intended to address the McKinney-Vento Homeless Education Assistance Improvements Act 42
3.5.0. 11435. The answers to this residency information help determine the services the student may be eligible to
receive.
Is your current address a temporary living arrangement?

Yes No
Is this temporary living arrangement due to loss of housing or economic hardship?

N/A
Where is the student presently living?

N/A
Is this student an unaccompanied youth?

Yes No
(An unaccompanied youth is a student who is not in the physical custody of a parent or legal guardian.
This would include students living with non-custodial relatives or friends without a parent or legal
guardian)
Page 13 of 30
Presenting a false record or falsifying records is an offense under Section37.10 Penal code and enrollment of the
child under false documents subjects the person to liability for tuition or other costs. TEX S.. 25.002(3) (d).
I certify that all the information on this form is true and that all income is reported. I understand the school will
receive federal funds and will be rated for accountability based on the information I provide.
Initials
MC
Page 14 of 30
MIGRANT INFORMATION
Your information is strictly confidential. It will not be shared or distributed.
If you have worked in temporary or seasonal jobs in agriculture or ranching; your child/children may qualify for
supplemental services at school through the Migrant Education Program. Help us determine if your children are
eligible for these additional services by answering a few questions and returning this completed survey to the
school.


TX 77045 MO
Guardian 2 First Name Guardian 2 Last Name Guardian 2 Mobile Phone Number
Juan Canales 713-754-0386
Guardian 2 Email Guardian 2 Home Phone Number Guardian 2 Work Phone Number
canalesnathaly8@gmail.com
Guardian 2 Address Street1 Guardian 2 Address Street2
2918 Trail Lake Drive
Guardian 2 Address City
Houston

TX 77045 Student
FA

Student Next Grade Level Student Birth Date

10 10/04/2006
Within the last 3 years (36 months) did you or one of your family members move to seek or find work in
agriculture or fishing?
Yes No
Family Member Name Family member relationship to student?

N/A N/A
Family member phone number Family member education level

N/A N/A
Where did you move from to look for work in the past 3 years (36 months)?
City (From) State (From) Country (From)

N/A N/A N/A
City (To) State (to) Country (To)

N/A N/A N/A
Please select all that apply

N/A
Page 15 of 30
If Other work related to agriculture please describe.
N/A
Page 16 of 30
Houston Transportation Form

Student Next Grade Level

10
Bus Route Selection
These are tentative stops for SY 2022-2023. Please select stop that is most convenient for your student. Stop
selection must be confirmed during your school's Orientation before the beginning of school year. Failure to confirm,
may result in your student losing their place on the bus.
Will this student need to ride the bus?

Yes No
By selecting yes, I confirming that I have read and understood the statement below.
N/A
Dear KIPP family Guaranteed transportation is now closed. Your request will be approved based on
available space. If there is no space on your requested bus, your student will be placed on a waitlist and
you will be updated on its status as space becomes available. Thank you for your understanding!
Morning Transportation Afternoon Transportation

N/A N/A
Select this student's school:

N/A
Please select the bus stop that is most convenient for your student:
KIPP Unity Primary

N/A
KIPP Academy West

N/A
KIPP Shine Prep

N/A
KIPP Academy Middle School

N/A
KIPP Houston High School

N/A
Page 17 of 30
KIPP Sharpstown College Prep

N/A
KIPP Sharp Prep

N/A
KIPP NEXUS Primary

N/A
KIPP NEXUS Middle

N/A
KIPP Dream Prep

N/A
KIPP 3D Academy
N/A
KIPP Generation Collegiate

N/A
KIPP Legacy Preparatory

N/A
KIPP Polaris Academy for Boys

N/A
KIPP Voyage Academy for Girls

N/A
KIPP Northeast College Preparatory

N/A
Page 18 of 30
KIPP Explore Academy

N/A
KIPP Intrepid Preparatory

N/A
KIPP East End High School

N/A
KIPP Peace Elementary

N/A
KIPP Liberation College Preparatory

N/A
KIPP Climb Academy

N/A
KIPP Prime College Preparatory

N/A
KIPP Zenith Academy

N/A
KIPP Spirit College Prep

N/A
KIPP Sunnyside High School

N/A
KIPP Journey Collegiate

N/A
Page 19 of 30
KIPP Journey Primary

N/A
KIPP Mosaic Primary

N/A
KIPP Mosaic Academy

N/A
By selecting yes, I confirming that I have read and understood the statement below.
N/A
Parents and guardians, please select your alternative form of transportation for the SY 2022-2023. Be
advised that currently, KIPP Connect does not offer bus transportation.
Page 20 of 30
2022-2023 KIPP Texas Parent and Student Acknowledgments and Releases

KIPP Texas Public Schools Student and Family Handbook Acknowledgement
The KIPP Texas Handbook, along with any supplements or appendices, are available online at the KIPP Texas
website for families to access at any time and are regularly updated. Click https://kipptexas.org/public-
information/student-parent-handbook/ to access the Handbook. If a family wishes to obtain a paper copy of the
Student Handbook, they may do so by making a request in a school office after the start of school. I have received,
and have access to, the KIPP Texas Public Schools Student and Family Handbook documents. I understand and
agree that it is my responsibility to read and familiarize myself with the policies and procedures contained in the
documents. I understand and agree that nothing in the Student and Family Handbook documents creates or is
intended to create rules or policies that replace the Commitment to Excellence or other non-negotiable expectations
for KIPP Texas Public Schools’ students. I also understand that policies outlined in the Student and Family Handbook
documents are subject to change at the district’s discretion. All updated handbook documents will be posted online
to the website mentioned above. I acknowledge that it is my responsibility to read and familiarize myself with the
student bus policy and understand that all policies included in this handbook also apply when riding the bus.
Violation of bus policies may result in suspension of bus services. I state that I have read, or will read, and fully
understand the KIPP Texas Public Schools Student and Family Handbook. By electronically signing you and your
child(ren) understand and agree to the above acknowledgments:
By electronically signing you and your child(ren) understand and agree to the above acknowledgments:
Type your signature here:

Maria canales
Cafeteria Purchase Restrictions
Do you allow your student to purchase additional a la carte food items or second helpings of school breakfast or
lunch foods? These items would be debited/charged to your student meal account.
Check Yes or No
Yes No
Initial here:
MC
Electronic Devices and Technological Resources Acceptable Use Acknowledgment
Each student is granted access to KIPP electronic devices and technological resources as appropriate, meaning
he/she may use KIPP computing devices, electronic communications systems/Internet access, and KIPP approved
web communication tools per policies as outlined in the handbook.
Page 21 of 30
By electronically signing you state that you and your child(ren) have read, or will read, and fully understand and
agree to the policies and consequences for violating the Acceptable Use Policy as outlined in the Student and Parent
Handbook.

Maria canales
School Year 2022-23 Student Directory Release
The Family Educational Rights and Privacy Act, or FERPA, permits KIPP Texas to disclose appropriately designated
directory information from a student’s education records without written consent. KIPP designates the following
information as directory information: student’s name, address(es), telephone number(s), photograph, e-mail address,
participating in officially recognized activities and sports, weight and height if a member of athletic teams, dates of
attendance, awards received in school, the most recent school attended, grade level, enrollment status. Directory
information shall only be released to: school officials for school-related purposes, school-related affiliates and
organizations that require directory information to provide services to KIPP including school photos, campus
directory, yearbook, newsletters, media articles, honors; and for secondary students to military recruiters and
institutions of higher education, as required by federal law. Directory information will be released to anyone listed
above who follows procedures for requesting it. However, a parent or eligible student may object to the release of a
student’s directory information in some cases.
Do you give KIPP Texas permission to use your child’s identified directory information, as listed above, for school
sponsored purposes or to provide this information to school related affiliates and organizations, for such items and
activities as the yearbook, KIPP programs for extracurricular activities (e.g. student performances and athletics),
etc.?
Please select your choice

I DO give KIPP permission to use my child’s identified personal information for school- sponsored
purposes I DO NOT give KIPP permission to use my child’s identified personal information for school-
sponsored purposes
Do you give KIPP permission to release your child’s name, address, and telephone number to a military recruiter or
institutions of higher education upon their request?

I DO give KIPP permission to release my child’s information to a military recruiter or institution of
higher learning I DO NOT give KIPP permission to release my child’s information to a military
recruiter or institution of higher learning
By electronically signing you and your child(ren) understand and agree to the above acknowledgment(s):

Maria canales
KIPP Texas Public Schools Media Release
Page 22 of 30
Throughout the school year, students may be highlighted in efforts to promote KIPP activities and achievements. For
example, students may be highlighted in materials to train teachers and/or increase public awareness of our schools
in newspapers, radio, TV, the web, brochures, and other types of media.
I hereby give KIPP and its employees, representatives, and authorized media organizations permission to print,
photograph, and record my child for use in audio, video, film, or any other electronic, digital and printed media. I
release KIPP, all KIPP schools, all KIPP affiliates, and their respective trustees, agents, and employees from all
claims, demands, and liabilities whatsoever with the connection of the use of such media materials. It is my
understanding that neither my child nor I will receive any compensation related to this release. If no option is
selected, this states that KIPP does not have permission to print, photograph, and record your child for the above-
mentioned uses.

I DO give KIPP permission to to print, photograph, and record my child for use in audio, video, film, or
any other electronic, digital and printed media. I DO NOT give KIPP permission to to print, photograph,
and record my child for use in audio, video, film, or any other electronic, digital and printed media.
By electronically signing you and your child(ren) understand and agree to the above acknowledgment:

Maria canales
Student Notification of Needs Assessment and Opt Out Letter
Dear KIPP Texas Families,
We thank you and your family for being our valued partners as we work together to educate the children in our
district. As you may already be aware, building our social-emotional learning skills is an important goal for our
school this year. During school year 2022-2023, students will participate in surveys to better understand these
concepts and to reflect on how they perceive these skills in themselves.
For children in grades PK-2 we will be sending these surveys for you to fill out with your little KIPPster. For children
in grades 3 through 12, we will be asking for your child to reflect on their own mindsets and approaches to learning
via an online survey they will be completing at school. The survey shouldn’t take more than 20-30 minutes to
complete. This survey will be administered three times a year, in September, January and May with additional
occasional check-ins throughout the year.
The survey content will ask students to self-reflect on their wellbeing, their school environment, and their own
strengths and skills.
We are asking that all of our students participate in the surveys, as their responses will provide invaluable insights
into their experiences and how we can improve and adapt our district to their needs. If a student doesn’t feel like they
have enough information to answer a question, they will be able to skip the item altogether. The responses to these
surveys will be completely confidential. We are partnering with a third-party vendor to support us in administering
these surveys.
If your child is in Grades 3 through 12, please notify us if you would like your child to opt out of taking the surveys by
filling in your name and your child’s name below. If your child is in PK4 through 2, you only need to complete the
surveys with your little KIPPster and do not need to sign this form. We thank you in advance for your thoughtful
responses. If you have any questions about the survey administration, please don’t hesitate me at
Page 23 of 30
maria.rivera@kipptexas.org.
Sincerely,
Maria Rivera, MD, MPH Managing Director of Student Wellness KIPP Texas
Are ok with your child participating in the surveys?

Yes No
By electronically signing you and your child(ren) understand and agree to the above acknowledgment:

Maria canales
Sign up to be a KIPP Texas Advocate!
Civic engagement is a key way that we can Champion Equity, and we need your voice! Fill out the form to get
connected with our Advocacy team. We’ll send you action alerts so you can stay updated and find out how to use
your voice to support the KIPP
Would you like to stay up to date on news that impacts the KIPP Texas community?
Yes No
Type your signature here: Today's Date

Maria canales 01/10/2022
By signing here, you’re agreeing to share the information provided in this form with KIPP Texas and its third-party
vendor, Murmuration, for use with our KIPP Texas advocacy software and other education-related advocacy
purposes and communications. This software, M{Insights}, is how we get the word out to our community about major
issues impacting our KIPPsters and how we keep track of our collective impact. M{Insights} partners with schools
and organizations across the country to promote online voter registration, non-partisan civic engagement, and voter
participation. Your data may be used for these purposes and may be shared with partnering affiliates, service
providers, and organizations, for business purposes, analysis and modeling, communicating with you, research
purposes, and for recordkeeping purposes. There is no requirement or charge to participate, and we hope you will
join us in this important effort!
Would you like to support the KIPP Texas Advocacy team?

Yes No
I would like to get involved by...

N/A
Please tell us what other way you would like to support the KIPP Texas Advocay team.
N/A
Parent Rights & Compliance Notifications
Please review all statements below:

Page 24 of 30
Consent for student participation in a federally-funded survey, analysis, or evaluation. The Protection of Pupil Rights
Amendment (PPRA) mandates that students will not be required to participate without parental consent in any survey,
analysis, or evaluation—funded in whole or in part by the U.S. Department of Education—that concerns:.
Political affiliations or beliefs of the student or the student’s parent;

Mental or psychological problems of the student or the student’s family;
Sexual behavior or attitudes;
Illegal antisocial self-incriminating or demeaning behavior;
Critical appraisals of individuals with whom the student has a close family relationship;
Relationships privileged under law such as relationships with lawyers physicians and ministers;
Religious practices affiliations or beliefs of the student or parents or
Income except when the information is required by law and will be used to determine the student’s eligibility
for a program.
Parents can inspect the survey or other instrument and any instructional material used in connection with such a
survey analysis or evaluation.
The right to opt out participation in other types of surveys or screenings and the disclosure of personal information
The PPRA gives parents have a right to receive notice of and deny permission for students’ participation in:
Any survey concerning protected information, regardless of funding.

School activities involving the collection disclosure or use of personal information gathered
from your child for the purpose of marketing selling or otherwise disclosing that information to
others.
Any non-emergency, invasive physical examination or screening required as a condition of
attendance, administered by the school or its agent, and not necessary to protect the
immediate health and safety of the student. Exceptions are hearing, vision, or spinal
screenings, or any physical examination or screening permitted or required under state law.
Parents may inspect:

Protected information surveys of students and surveys created by a third party;
Instruments used to collect personal information from students for any of the above marketing,
sales, or other distribution purposes; and
Instructional material used as part of the educational curriculum.
Right to request state or district policy related to a student’s participation in state assessments. In accordance with
the Every Student Succeeds Act (ESSA), parents may request information regarding any federal, state, or district
policy related to their students’ participation in required assessments. Opportunity to enroll in the Texas Virtual
School Network-(Secondary Grade Levels)The Texas Virtual School Network (TXVSN) has been established by the
state as one method of distance learning. A student has the option with certain limitations to enroll in a course
offered through the TXVSN to earn course credit for graduation.
In addition for a student who enrolls in a TXVSN course for which an end-of-course (EOC) assessment is required the
student must still take the corresponding EOC assessment. If you have questions or wish to make a request that
your child be enrolled in a TXVSN course please contact the school counselor. Unless an exception is made by the
school principal a student will not be allowed to enroll in a TXVSN course if the school offers the same or a similar
course.
Notification of compliance with state and federal guidelines related to asbestos management. The District works
diligently to maintain compliance with applicable federal and state law governing asbestos in school buildings. A
copy of the District’s Asbestos Management Plan is available in the superintendent’s office. If you have any
questions or would like to examine the District’s plan in more detail please contact Brad Welter the District’s
designated asbestos coordinator at 832.328.1051 ext. 1903.
Notification of compliance with state and federal guidelines related to pest management. Although the District strives
to use the safest and most effective methods to manage pests including a variety of non-chemical control measures
pesticide use is sometimes necessary to maintain adequate pest control and ensure a safe pest-free school
environment. All pesticides used are registered for their intended use by the U.S. Environmental Protection Agency
and are applied only by certified pesticide applicators. Except in an emergency signs will be posted 48 hours before
indoor application. All outdoor applications will be posted at the time of treatment and signs will remain until it is safe
Page 25 of 30
to enter the area.
I have read the above statements
Initial here:
MC
Compulsory Attendance Notice

Student Birth Date Student Next Grade Level

10/04/2006 10
Texas Education Code Sec. §25.095
TO: PARENT(S)/GUARDIAN(S) of students in KIPP Texas Public Schools. This notice is to be read, signed and
returned to your child’s campus.
TEC Sec. §25.095. Warning Notice
If a student is absent for three (3) or more days or parts of days in a four-week period or for ten (10) or more days or
parts of days in a six-month period within the same school year:
a. the student’s parent/person standing in parental relation is subject to prosecution for “Parent
Contributing to Nonattendance” under Texas Education Code Section §25.093; and
b. the student is subject to prosecution for “Failure to Attend School” under TEC Section
§25.094.
It is your duty as a parent or person standing in parental relation to the student to monitor and require regular school
attendance, and you and/or your student could be subject to a fine for excessive unexcused absences.
TEC Sec. §25.085. Compulsory School Attendance states:
a. A child who is required to attend school under this section shall attend school each school day
for the entire period the program of instruction is provided.
b. Unless specifically exempted by Section 25.086, a child who is at least six (6) years of age, or
who is younger than six (6) years of age and has previously been enrolled in first (1 st) grade,
and who has not yet reached his/her 18 th birthday, shall attend school.
c. On enrollment in prekindergarten or kindergarten, a child shall attend school.
You will be notified if your student has excessive absences from school without excuse and a conference between
you and school officials will be requested to discuss the absences. Should the absences continue or your student
fail to meet the state’s Compulsory School Attendance Law, KIPP Texas will file “Failure to Attend” paperwork with
the court.
Parent or Guardian Signature: Today's Date

I understand that it is important to bring my KIPPster to school each day in effort to maintain 100% attendance so that
my KIPPster can excel academically at school.
Initial here:
Page 26 of 30
MC
I understand that I need to return school communications within one school day
Initial here:
MC
I understand that my child is missing instruction on the basics of reading and math when the child is late absent or
picked up early. I will maximize my child’s time in school.
Initial here:
MC
I understand that if there is inclement weather the school will notify me via email, phone or text. If I am not notified
that school is closed I am expected to have my child at school every day.
Initial here:
MC
I understand that KIPP Texas has the right to file truancy if my KIPPster's unexcused absences exceed 9 days within
a six month time period. This is subject to change based on the KIPP Texas truancy rules.
Initial here:
MC
Registration Authorization
The electronic signature below and its related field(s) are treated by KIPP Texas Public Schools like a handwritten
signature on a paper form. I confirm the information provided is accurate as of today's date.
I agree that I have received all appropriate information. I also agree that this is the only Registration Form being
submitted for this child.
The information asked above is needed as a permanent school record of your child and will be used by school
personnel. This is to certify the above information is correct.
I the undersigned do hereby authorize officials of the school to contact directly the person named on this form and do
authorize the above named physician to render such treatment as may be deemed necessary in an emergency for
the health of said child. In the event physician other person on this form or parents cannot be contacted the school
officials are hereby authorized to take whatever action is necessary in their judgment for the health of the aforesaid
child. I will not hold the school district responsible for the emergency care and/or transportation for said child.
I understand that the Texas Penal Code Section 37.10 states that it is an offense to (1) make a false entry or false
alteration of a government record (2) present a document with knowledge of its falsity or (3) impair the verity or
legality of the record. I further understand that the Texas Education Code Section 25.001(h) states that it is an offense
to knowingly provide false information on a form required for enrollment of a student. Offenses may result in legal
actions including but not limited to fines and/or liability for payment of tuition. TUITION: The amount of expense
required from local funds.
Note: Information submitted on this application will be verified. If a student is determined to be eligible during pre-
Page 27 of 30
registration but ineligible during August verification he/she will be unable to participate in the program. Student
enrollment and the preference plan will determine program location.
Do you agree to the statement above?
Parent/Guardian's Signature: Today's Date

Page 28 of 30
I am satisfied with my child's education when my child is (please select your top choice):
Getting good scores on state/national standardized tests. Achieving at or above grade level.
Being prepared for post-secondary education (i.e. college or university). Developing friendships and
social skills. Being given opportunities to participate in extra-curricular activities aligned to their
interests. Enjoying school.
What best describes how much input students and families have on school decisions?
Students and families are partners with staff and always part of decisions for the school. Staff
regularly ask students and families questions to help them make decisions and listen to what they share.
Staff sometimes ask students and families questions to help them make decisions, but don’t always
listen. Staff make all the decisions - students and families are not involved.
In what ways are you able or would like to be involved in your child's school? Please select all that apply.
Volunteering at the school or school events Attending school events (Orientation, Meet the
Teacher, Open House) Parent Committee / Group (PTA or PTO) Workshops / Opportunities to
learn together how to collaborate to improve student achievement Parent Teacher Conferences
Extracurrilar Events Other
Is there another way would you like to be involved in your child's school?
What obstacles prevent you from engaging with your child's school? Please select all that apply.
Time / Work Schedule Poor Communication / Not aware of opportunities Language
Transportation Not Interested Childcare Previous negative experience Too time
consuming Attendance is not required
What are your favorite school events to attend? Select all that apply
Orientation / Open House / Meet the Teacher Academic / Report Card / Credit / Grade Monitoring
Cultural Events Student Performances / Sporting Events KIPP Forward / College & Career
Award Ceremony / Graduation Parent Meetings / PTA / PTO Parent Workshops
My child’s teachers are receptive to my input and suggestions.

Strongly Agree Agree Somewhat Agree Neutral Somewhat Disagree Disagree
Strongly Disagree
How does your child's school most often communicate with you?
School-provided app (e.g. Class Dojo, Flyer app, Remind, etc.) Email Text Phone call
Letter home KIPP Texas website (www.kipptexas.org) Social media All the above
What is your preferred method of communication from your child’s school?

School-provided app (e.g. Class Dojo, Flyer app, Remind, etc.) Email Text Phone Call
Letter home KIPP Texas website (www.kipptexas.org) Social Media All the above Other
Which method of communication best describes how you are informed of news about other KIPP Texas schools
and/or KIPP Texas at-large?
Weekly message from Sehba Ali, KIPP Texas CEO Other email Text Phone Letter
home Social media KIPP Texas website (www.kipptexas.org) School-provided app (e.g. Class
Dojo, Flyer app, Remind, etc.) All of the above I am not familiar or notified of information outside of
my child’s school Other
How often do you talk directly with a school based staff member?
Page 29 of 30
Multiple times a week Once a week 2 -3 times a month Once a month Every few
months or less
Are you satisfied how often your child's school communicates with you?
Yes, they communicate enough. No, they communicate too much. No, they communicate too
little.
Why did you choose KIPP over another school? Please select your top choice.
Academics / High Expectations KIPP Forward / College & Career Focus Extracurricular
Activities Teachers / School Leaders Character / Social Emotional Learning Free Breakfast &
Lunch Free Transportation Location / Proximity to home Family / Friend Referral Other
If Other, please explain

N/A
Page 30 of 30

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Student

First Name Middle Name Last Name

Student Lives With Date of Birth Gender

Grade entering next school year

School entering next school year

Home Address 2918 Trail Lake Dr

Apartment, Unit, or Suite Number

State City Zipcode

Mailing Address Information

Mailing Address 2918 Trail Lake

Apartment, Unit, or Suite Number

Mailing State Mailing City Zipcode

Relationship to First Name Last Name

Home Phone Work Phone Mobile Phone

Email Address canalesnathaly8@gmail.com

Guardian Address Information

Address Street 1 2918 Trail Lake Drive

Apartment, Unit, or Suite Number

State City Zipcode Relationship to

Home Phone Work Phone Mobile Phone

Email Address canalesnathaly8@gmail.com

Guardian Address Information

Address Street 1 2918 Trail Lake Drive

Apartment, Unit, or Suite Number

State City Zipcode Relationship to

Home Phone Work Phone Mobile Phone

Email Address canalesnathaly8@gmail.com

Guardian Address Information

Address Street 1 2918 Trl Lk Dr

Apartment, Unit, or Suite Number

State City Zipcode Relationship to

Home Phone Work Phone Mobile Phone

Email Address canalesnathaly8@gmail.com

Guardian Address Information

Address Street 1 3302 Dalmatian Dr

Apartment, Unit, or Suite Number

State City Zipcode Relationship to

Home Phone Work Phone Mobile Phone

Guardian Address Information

Address Street 1 3302 Dalmatian Dr

Apartment, Unit, or Suite Number

State City Zipcode Relationship to

Home Phone Work Phone Mobile Phone

Email Address canalesnathaly8@gmail.com

Guardian Address Information

Address Street 1 2918 Trail Lake Lane

Apartment, Unit, or Suite Number

State City Zipcode

This section is to update your family information. Please follow these

Guardian Address Street1 Guardian Address Street2 Guardian Address City

Guardian Address State Guardian Address Zipcode Guardian Relationship to Student

Guardian Education Level Guardian 2 First Name Guardian 2 Last Name

Guardian 2 Address Street1 Guardian 2 Address Street2 Guardian 2 Address City

Guardian 2 Address State Guardian 2 Address Zipcode Guardian 2 Relationship to

Guardian 2 Education Level

Do you need to update the guardian ID on file?

(For example Passport, driver's license, or government-issued ID with photo.)