Certificate of Elligibility for Migrant Education Program

Certificate of Eligibility (COE)

COE Record Number: ____________________

I. FAMILY DATA

Current Male Parent (Last name, First): _____________________________-______________________________

Current Female Parent (Last name, First): ): _____________________________-______________________________

Parent type:  Birth  Adoptive  Legal Guardian  Guardian (in loco parentis)  Undisclosed

Parent type:  Birth  Adoptive  Legal Guardian  Guardian (in loco parentis)  Undisclosed

Current Address: _____________________________________________________________________ City:________________________________ State:_______ Zip:____________ Telephone: (_________)______________________

Homebase Address: ___________________________ City:_________________________________ State:_______ Zip:___________ Telephone: (_________)__________________ Homebase District: ___________________________

II. CHILD/SCHOOL DATA

The children listed below arrived in the present school district, ______________________________________________, on ______________________________ from ________________________________________________________ . Name of School District Residency Date (Month, Day, Year) School District, City, State, Country

Last Name

Last Name

Suffix

First Name

Middle Name

Gender

Ethnicity

Birth Date

Verification

Birthplace

School

Grade

Education Interruption

Enrollment Date

State ID No.

MSIX ID No.

III. ELIGIBILITY DATA

The child(ren) listed above made a qualifying move from ______________________________________________________ to _________________________________________________ on ____________________________________ . School District/City/State/Country School District/City/State Qualifying Arrival Date (Month, Day, Year)

The child(ren) moved  on own (as a worker), or  with  to join (the worker): _________________________________________ who is the  parent  spouse  other family member: ________________________________________ . (mark one) First and Last Name of Worker (mark one) Relationship (if other family member)

This worker moved in order to  obtain  seek |  temporary  seasonal employment | in  agricultural  fishing work __________________________________________. (If the move was made in order to obtain “temporary” employment (mark one) (mark one) (mark one) Describe Agricultural or Fishing Work

explain how that determination was made in the comment section below.) The qualifying employment plays an important part in providing a living for the worker and his/her family because: ________________­­­­­__________________________ ______________________________________________________________________________________________________________________________________________________________________________________________ .

Comments:  Additional comments attached.

IV. PARENT/GUARDIAN/WORKER SIGNATURE

V. ELIGIBILITY DATA CERTIFICATION

The purpose of this form is to help the State of __________________________ determine if the children/youth listed above are eligible for the Title I Migrant Education Program. I have provided the information recorded above. To the best of my knowledge all of the above information is true. ______________________________________ ___________________ ________________ Signature Relationship Date (Month, Day, Year)

I certify that these students are eligible for MEP services based on the information provided by the parent/guardian/worker identified in the box to the left. I hereby certify that, to the best of my knowledge, the information is true, reliable, and valid. Any false statement provided herein is subject to fine or imprisonment pursuant to 18 U.S.C. 1001. _________________________________________________________________ ______________________ Signature of Interviewer Date (Month, Day, Year) _________________________________________________________________ ______________________ Signature of Designated SEA Reviewer Date (Month, Day, Year)

Revised: 1/23/07