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Date:	Referred by:

Email:	Phone:	Ext.

Parent Information
Parent’s Name:
Address:
City:	Zip	County:
Email:
Home Phone:	Cell Phone:	May we text you? Yes No

Children in Home

Name	Age	DOB	Grade	School/Daycare

Parent/Student Services

What type of services are you interested in? Check all that apply.

Pre-K (birth-5yrs)	Read, Set, Read (K-5th)	Operation Middle (6th – 8th)	Race to 100 (9th -12th)

College Prep	Workshops	Entrepreneur Coach	EOG/EOC Resources

Scholarships	Tutorials	Career Prep	Prayer

Attend Meeting (ex. IEP/Section 504/Conference)

Other: ____________________________________________	Other: _________________________________________

Comments:

TMS STAFF ONLY: Donation Type: Quarterly (9wks) Annually Community Service

AGI: _____________ VERIFICATION TYPE: _____________________VERIFIED BY: _______________________________

County: __________________________LEA CODE: _____________

Internal Audit by: ___________________________________ QCID: ______________ Date: ________________