School Form 604(2)
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DEPARTMENT OF HUMAN RESOURCES FAMILY INVESTMENT ADMINISTRATION Department of Social Services SCHOOL VERIFICATION FOR ELEMENTARY & HIGH SCHOOL – ONLY SECTION I: TO BE COMPLETED BY FI WORKER Control #
District Office:
Worker’s Name:
Category and Case#:
Worker’s Phone:__________________________________
Case Name:
Please provide the information requested below about who is a student at your school. The information will be used to determine his/her eligibility for one of our programs. Consent to release this information is provided in Section II below. SECTION II: TO BE COMPLETED BY PARENT FOR MINOR CHILD OR STUDENT FOR HIMSELF IF OVER 18 , hereby authorize Name of School
to release to the Department of Social Services information concerning school enrollment, for the purpose of redetermining eligibility. Signature
Date
SECTION III: TO BE COMPLETED BY SCHOOL
A. Type of Enrollment: 1 Secondary School (public or private) 1No
B. Is the student full-time 1Yes C. Expected date of graduation:
1Vocational School
1Technical School
Date (Month & Year)
D. Attendance record: 1Regularly attends, except for occasional sickness 1Not attending E. Home address and telephone number of student: Address (Number and Street): City, State, and Zip Code: Telephone Number: F. Full names of all parents/legal guardians listed in student’s home: 1. Work Phone#: Work Phone#: 2. G. Emergency phone numbers:
Name and Address of School Institution (PLEASE USE SCHOOL STAMP)
DHR/FIA 604 (Revised 8/96) Previous editions are obsolete.
District Office:
Worker’s Name:
Category and Case#:
Worker’s Phone:__________________________________
Case Name:
Please provide the information requested below about who is a student at your school. The information will be used to determine his/her eligibility for one of our programs. Consent to release this information is provided in Section II below. SECTION II: TO BE COMPLETED BY PARENT FOR MINOR CHILD OR STUDENT FOR HIMSELF IF OVER 18 , hereby authorize Name of School
to release to the Department of Social Services information concerning school enrollment, for the purpose of redetermining eligibility. Signature
Date
SECTION III: TO BE COMPLETED BY SCHOOL
A. Type of Enrollment: 1 Secondary School (public or private) 1No
B. Is the student full-time 1Yes C. Expected date of graduation:
1Vocational School
1Technical School
Date (Month & Year)
D. Attendance record: 1Regularly attends, except for occasional sickness 1Not attending E. Home address and telephone number of student: Address (Number and Street): City, State, and Zip Code: Telephone Number: F. Full names of all parents/legal guardians listed in student’s home: 1. Work Phone#: Work Phone#: 2. G. Emergency phone numbers:
Name and Address of School Institution (PLEASE USE SCHOOL STAMP)
DHR/FIA 604 (Revised 8/96) Previous editions are obsolete.
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