45
Tolleson Union High School District Supplemental Education Services Provider Guidebook SY 2011 – 2012
Tolleson Union High School District
Supplemental Education Services
Provider Guidebook
SY 2011 – 2012
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ontentsidebook Intro
trict Contact
dent Enrollm
Qualifying Stu
Completing th
rent Outreach
School Sponso
Canvasing by
Provider Fair .
dent Attenda
ndor Registra
e of TUHSD Fa
toring Schedu
nsportation ..
ogram Quality
Progress Repo
Dismissal Poli
pendix A: For
TUHSD Vendo
TUHSD Vendo
RS Form: W‐9
Arizona Depa
TUHSD Facility
Parent Applic
ADE Supplem
pendix B: Add
TUHSD Use of
pendix C: Pro
SES Incident R
SES Coordinat
SES Tutor Obs
oduction .......
Information .
ment Overview
udents ..........
he Supplemen
h ...................
ored Outreac
SES Providers
.....................
ance .............
tion and Set‐
acilities .........
ules and Locat
.....................
y and Monito
orts ..............
cy .................
ms ...............
or Contract fo
or Registratio
9 ...................
rtment of Edu
y Use Agreem
ation for Sup
ental Educati
ditional Guida
f Facilities Pro
gram Monito
Report ..........
tor Report ....
servation For
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w ...................
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ntal Educatio
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ch ..................
s ...................
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up ................
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tions .............
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ring ..............
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or Supplemen
n Application
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ucation Canva
ment .............
plemental Ed
ional Services
ance ..............
ocedures, Pol
oring and Rep
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n Services (SE
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ntal Education
n ....................
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asing Agreem
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ducational Ser
s Agreement .
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icies, and Ren
orting ...........
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GuTheEducomSch TheessthrDisconcon Toltheof a
DiDis
DisDivPurFacSESSES Cop
StuTolwitThegui ToldurJanat e
uidebooke following iucational Semplies with hool District.
e purpose ofsential elemerough the fostrict to optimntacting distncern is not
lleson Unione Arizona Deassisting stu
strictConstrict Mailing
TollesoDr. Josh9801 WTolleso
strict Phone vision/Deparchasing .....cility Use .....S DocumentS Coordinato
pper Canyon
udentEnrlleson Unionth regulatione district wilidance.
lleson Unionring the seconuary. Pareneach campu
Introducnformation rvices (SES) law and regu. Included ar
f this guidebents to supprms, policiesmally providtrict or schooaddressed in
n High Schooepartment ofdents in imp
ntactInfog Address fon Union High Dean, DireWest Van Burn, AZ 85353
Contacts forrtment ......................................ation Procesor ................
n High Schoo
rollmentn High Schoons we are agl engage in s
n High Schooond half of Snts are encos will have t
ctionis provided to eligible Tulation, and re program c
book is to proport our parts, and procede the servicol personneln this guideb
ol District wef Education. proving their
ormationr SES Vendoh School Disctor of Schoren
r SES Vendo
...................
...................ssing ..............................
ol ................
Overviewol District #2ggressively pstudent enro
ol district wilSeptember auraged to inhe necessar
in order to folleson Uniois functionacriteria, ope
ovide SES Prtnership. Thdures contae needed tol. You are enbook.
elcomes all SWe invite yr academic p
ors: strict ool Improvem
rs: Phone
.......... 623‐4
.......... 623‐4
.......... 623‐4
.......... 623‐4
.......... 623‐4
w14 has schooursuing Supollment as e
l offer two wand the seconquire aboutry knowledge
facilitate theon High Schoal for both thrational para
roviders withhis resource ained hereino support yoncouraged to
Supplementaou to join usperformance
ment
e Number478‐4005 ....478‐4038 .....478‐4013 .....478‐4012 .....
478‐4861 .....
ols in NCLB/plemental Explicitly out
windows of end enrollmet SES with the to respond
e provision oool District (The provider aameters, fisc
h a comprehdescribes th. In order four efforts plo contact us
al Educations as instructe.
....................
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/ESEA SchooEducational Slined in regu
enrollment fent window he school dird to parent/
of Title I, ParTUHSD) studand the Tollcal details, a
hensive docuhe foundatioor Tolleson Uease consuls if your com
nal Services pional partne
....................
....................
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l ImprovemeServices (SESulatory and n
for SES. The will be durinrectly. The ccommunity
t‐A Supplemdents in a meson Union and other gu
ument that cons of our reUnion High St this resour
mment, ques
providers apers in the com
Conta.............. Che............ Jenn........... Dalia.............. Dr.
.............. Min
ent. In accorS) for eligiblenon‐regulato
first windowng the seconcustomer sery inquires. Sc
mental anner that High uidance.
contains all lationship School rce prior to stion, or
pproved by mmon goal
act Personeryl J. Burtnifer Edens OntiverosJosh Dean
ndy Marsit
rdance e students. ory
w will be nd half of rvice staff chool staff
wilpro
QuSupattinteinteacafun The
Pur
pro
CoOn
Agr
mo
All
rep
eac
sch
Tut
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Pa
SchTol
Par
fro
we
the
sch
l be able to ovide genera
ualifyingSpplemental endance is ierested in reerested pareademically nnding is exha
e SES provid
rchase Orde
ovider with a
ompletingly official co
reement ma
odified from
sections of t
presentative
ch SES Agree
heduling you
toring servic
e current fisc
hool personnS Agreementated reasonhool SES coo
arentOutr
hoolSponlleson Union
rents of stud
m the princi
ebsite, the di
e school mar
hool newspa
provide pareal informatio
tudentsEducational n year two oeceiving Supents/ studeneedy will beausted.
er is not aut
r is issued.
an existing p
theSuppleopies of the A
ay be used fo
their origina
the SES agre
before subm
ements is fift
ur first tutori
ces may not
cal period w
nel will workt. However,. Therefore,ordinator can
reach
nsoredOutn High Schoo
dents who q
ipal that incl
istrict websit
rquee will an
per will con
ents with anon on SES. H
Services areof school impplemental Ents will be rae served first
thorized to b
Purchase or
purchase ord
ementalEArizona Dep
or students i
al form will n
eement mus
mitting it for
teen days; b
ing session.
be initiated
ith the spec
k with SES Pr, it is not acc, the documn make a be
treachol District wil
ualify for SE
ludes an inv
te, informat
nnounce the
tain an SES a
n SES ApplicaHowever, no
e available oprovement.Educational Sank‐ordered t in sequenti
begin service
ders will be
der must wai
Educationartment of E
n Tolleson U
not be accep
t be comple
r review by t
beginning on
prior to obt
ific student
roviders to fceptable to ients must bll schedule a
ll spend up t
S services ar
itation to th
tion will be a
e provider fa
announceme
ations and th staff memb
nly to eligibShould we bServices duebased on acial order fro
es and no co
issued/ revi
it for a revis
Services(Education Su
Union High S
pted.
ted in full an
the site repr
n the submis
aining confir
named in th
acilitate thenterrupt inse completedavailable upo
to 1% of the
re notified o
e provider f
available to p
ir, flyers wil
ent.
he provider ber will endo
le TUHSD stbe unable toe to insufficiecademic achm the lowes
ontract is for
sed for indiv
ed PO befor
(SES)Agreupplementa
School Distri
nd signed by
resentatives
sion date. P
rmation of a
he purchase
e completionstructional tid outside thon request.
Title I‐A Allo
of the opport
fair, an autom
parents at se
l be posted
list. All stafforse a provid
udents whoo serve all stent funding,hievement, ast performin
rmed until a
vidual stude
re serving an
eementl Educationa
ct. Any cop
y the parent
. The total p
Please plan a
a valid distric
order.
n of the collame to compe student’s s
ocation on S
tunity via a d
mated phon
elect school/
by commun
s are will beder.
se school ofudents/pare, all qualifiedand the mostng to the hig
n authorized
nts. Therefo
ny new stude
al Services (S
ies that have
and vendor
processing tim
accordingly w
ct purchase
aboratively dplete for anyschool day.
SES parent o
direct comm
ne message,
/ community
ity partners,
able to
f ents d and t hest until
d District
ore, a SES
ent.
SES)
e been
r
me for
when
order for
developed y SES The
utreach.
munication
the school
y events,
, and the
CaWecomMa ThiDea laschPro
PrAll of tfair Theparoveprolocit isexclocTolrep Gu
StuIt is
Stu
ser
Stu
rec
anvasingbe understandmmunicationap is availabl
is section wipartment ofack of alignmhool district ovider a brea
oviderFaiADE approvthe providerr notice for p
e agenda forrents to inteerview of theocess. After ation. Each s an expectaception of reation. Unetlleson Unionported to the
idance from
RepreseSES rep
Provide
Rewardapprop
udentAtts a responsib
udent Attend
rve as verific
udent Attend
ceive payme
ySESProvd the importns with the ple on the dis
ll not addresf Education. ment betweeconsiders faach of contra
irved providerr fair in Septparent delive
r the provideeract with pre event and this brief inprovider wilation that allestroom visitthical conducn High Schooe Arizona De
m the Arizona
entatives mupresentative
ers should no
ds for prograriate.
tendancebility of the
dance Forms
cation that st
dance Forms
nt for any se
viderstance of canparents of qstrict website
ss the issuesThe failure ten the ADE gilure to comact.
rs serving theember. All ery and revi
er fair will inoviders. At the rudimentroduction tl have a tab providers rets by providect (by any stol District Direpartment o
a Departmen
ust wear namfrom a spec
ot send mor
am completio
SES tutor to
s with origin
tudents have
s are vital to
essions for w
vasing and eualifying stue at: http://w
s covered in to reiterate guidance andmply with AD
e Tolleson Ustudents whew.
nclude a briethe onset ofntary procesto the procele and be abemain withier representtakeholder) arector of Schof Education
nt of Educat
me badges tcific
e than two o
on cannot e
monitor stu
al student s
e attended t
the docume
which attend
encourage pudents. The Twww.tuhsd.
the guidancspecific guidd district expDE guidance r
Union High Scho qualify fo
ef parent ovef the event asses associatss, the parenble to share tn five feet otatives). Venat the providhool Improvevia an SES In
ion declares
that enable p
or three rep
xceed a valu
udent attend
ignatures or
tutoring sess
entation of S
dance forms
providers to Tolleson Un.org/filestore
ce communicdance from tpectations. regarding pr
chool Districor SES service
erview followa TUHSD stated with SESnts/ studenttheir servicef their tablendors are noder should bement. Grievncident Repo
s the followin
parents to e
resentatives
ue of $25.00
dance. Prov
r initials with
sions for wh
SES provider
are not or c
engage in opion High Sche/DistrictBo
cated to prothe ADE shoIn fact, Tollerovider canv
ct annually res are provid
wed by an off member wS provider rets will be dires with the pe or exit the fot to roam frbe reported tvous misconort.
ng guideline
asily identify
s to a fair.
0 and must b
iders must s
h each invoic
hich TUHSD i
rs’ services.
cannot be pr
pen honest hool District oundaryMap
oviders by thuld not be ceson Union Hvasing by an
receive an emded with a p
pportunity fwill provide elationships ected to theparents. Durfacilities (wireely in the fto Dr. Josh Dnduct should
es for SES pro
y each perso
be education
submit their
ce as these f
s being invo
Providers w
rovided.
Boundary .pdf
he Arizona considered High SES
mail notice provider
for the a brief and the e ‘fair’ ing the fair th the fair Dean, d also be
oviders:
on as an
nally
own
forms shall
oiced.
will not
Afte
from
Spe
sus
VeTo
Hig
Ple
er the first ab
m the progra
ecific details
staining SES
endorRegensure time
gh School Dis
Vendor
Site Org
Vendor
Union H
Directo
o
o
o
o
o
o
ease allow fo
bsence, the ve
m. These abs
s regarding t
services are
gistrationely and effici
strict has ve
rs wishing to
ganizational
rs who serve
High School
or of School I
To confirm with TUHSDContract forTo ensure seTUHSD VendVendors utiinclude prooCertificate HVendors notspecific datesessions at t(including ststudent homVendors muFingerprint DeclarationTo ensure in
Education C
or up to fifte
endor must n
sences do no
he district’s
outlined in
nandSet‐ent manage
ry specific p
o provide ser
meeting (se
e TUHSD stud
District offic
mprovemen
understandiD to serve stur Supplemenervices provdor Registralizing schooof of insuranHolder and nt utilizing sces, times, anthose speciftreet addresmes or in theust submit (aClearance C Form. ntegrity in th
Canvasing Ag
en (15) busi
notify the pare
t have to occ
attendance
the TUHSD
upement of sch
rocedures fo
rvices to Toll
ee vendor fa
dents must c
ce at 9801 W
nt:
ng of the reudents qualintal Educatiovided by purcation Applical facilities mnce with Tollnamed as anchool facilitiend locations fied locationsses, floor loeir own homand maintainard prior to
he provider c
greement m
ness days to
ent that a sec
ur consecutiv
expectation
Vendor Cont
hool/district
or establishi
leson Union
ir invitation
complete an
W. Van Buren
quirements ifying for SESonal Serviceschasing depation and a Wmust completleson Union n Additional es must notiwhere tutors. Providers cations, and
mes. n) a list of Tuinitiating tu
canvasing pr
ust be on file
o process the
cond absence
vely. The Dist
ns and repor
tract for Sup
and SES pro
ng our partn
High Schoo
for meeting
nd return the
n Street, Toll
and stipulatS students ms must be suartment areW‐9 te a TUHSD F High SchooInsured. ify in writingring will takemust be surd room num
utors with a toring servic
rocess, a sig
e at the dist
e aforement
e will result in
trict will pay f
rting require
pplemental E
ovider relatio
nership.
l District stu
g date).
e following f
leson, AZ 85
tions associamust submit ubmitted e timely plea
Facility Use Al District list
g the School e place priorre to includebers). Vendo
copy of the ces using the
ned Arizona
trict office.
tioned docum
n the child be
for up to 2 ab
ements rega
Educational
ons, Tolleson
udents must
forms to Tol
5353 in care
ated with pathe TUHSD
ase complete
Agreement ated on the po
SES Coordinr to commene exact locators may not
front and bae TUHSD Tut
a Departmen
ments.
ing dropped
bsences.
rding
Services
n Union
attend a
leson
of
artnering Vendor
e the
and olicy as the
nator of ncing tions teach in
ack of the tor
nt of
UsTolaccspechasuppruconreq YouTU
TuProwhsurma If aprositenew
TrTolprofortra
PrTheproroleAgrhon
seofTUHlleson Unioncordance witecific times oarge. The idpport schooludent to havntract. Therequest with th
u are encourHSD Use of F
utoringScoviders musthere tutoringre to includeay not teach
a tutoring sitovider MUSTe. Parents shw location.
ransportalleson Unionoviders will br working witnsportation
rogramQue Arizona Deogram qualite of the distreement thanored and th
SDFacilitn High Schooth the TUHSoutlined in tentification l staff and mve district staefore if you dhe School SE
raged to revFacilities Pro
chedulesat submit a lisg will take ple exact locatin student h
te changes aT inform the hould be not
ationn High Schoobe responsibth parents to.
ualityandepartment oty. Appendixrict is to assat content alhat all safety
tiesol District wilD Use of Fache TUHSD Vand selectio
maintain fiscaaff available desire to useES Coordinat
view the TUHocedures, Po
andLocatst, in writingace prior to ions (includihomes or in t
fter the schoSchool SES tified as soon
ol District wible for provido arrange tra
dMonitorof Education x C contains ure that theigns with thy and health
ll allow SES pcilities ProceVendor Contron of the timal integrity. to monitor e the schooltor.
HSD Vendor olicies, and R
tionsg to the Schocommencinng street adtheir own ho
ool coordinaCoordinatorn as possible
ll not providding transpoansportation
ringhas specific specific doc
e provider’s pe school curh laws are me
providers thedures, Policiract the schomes listed in tTUHSD doesSES facility u facilities, it
Contract forRental Agree
ool SES Coordng sessions addresses, floomes.
ator has beer of the site ce of the chan
de transportaortation (for n. Please no
forms and/ocuments thaprogram merriculum andet.
e opportuniies, and Renool will makethe contracts not have thuse outside is advised th
r Supplemenement for mo
dinator, of sat those specor locations
n informed change BEFOnge after the
ation for SESthose provite – SES pro
or expectatit will be useeets the requd state stand
ity to use thental Agreemee limited fact are based uhe fiscal resothe times idhat you pre‐
ntal Educatioore informat
specific datecified locatio, and room n
of a particulORE tutoringe District ha
S students. Tders who ofoviders are n
ions for howed to assess uirements pdards, that p
e facilities inent. During cilities availaupon the neources, nor entified in t‐schedule yo
onal Servicestion.
es, times, andons. Providenumbers). V
lar location, g begins at ts been infor
Therefore, Sffer transpornot required
w the districtprogram quromised in tprivacy issue
n the able free of eed to is it he our facility
s and the
d locations ers must be Vendors
the hat new rmed of the
ES rtation) or to provide
t monitors ality. The the SES s are
PrIn aparrep
Thea cbehrepedudis
DisBreSup
No
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ogressReaddition to trents with an ports should b
ese reports momplete undhavioral respports are notucation to ntrict.
smissalPoeaches of copplemental E
otes
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portsthe aforemeaccurate repbe submitted
must be timderstanding ponses to tht issued accootify the pro
olicyntract may rEducational
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ntioned formort of studento the Schoo
ely, informaof how thei
he academic ording to stipovider that h
result in the Services for
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ms, Tolleson nt performancl SES Coordin
ative and wrir child is proprogram, bupulations in he will be dis
dismissal. Pspecific det
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Union High Sce and growthnator.
itten clearly ogressing. Thut instead inthe contracsmissed if tim
Please reviewails regardin
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School Districth at least mo
free of educhese reportsnclude real at, we are reqmely reports
w the TUHSDng dismissal.
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t expects theonthly. Addit
cation jargos should not academic infquired by ths are not rec
D Vendor Co.
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SES Providertionally, stude
n so that pa simply incluformation. Ifhe departmeceived by pa
ontract for
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r to supply ent progress
rents have ude f these ent of rent and
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11
Tolleson Union High School District
Appendix A: Forms
12
TOLLESON UNION HIGH SCHOOL DISTRICT VENDOR CONTRACT FOR SUPPLEMENTAL EDUCATIONAL SERVICES
TUHSDVendorContractforSupplementalEducationalServices
Vendor Information Company Name ____________________________________________________________________________ Contact ____________________________________________________________________________ Billing Address ____________________________________________________________________________ City __________________________________________ State _______ Zip ________________ Office Phone # ____________________________________________________________________________ Fax # ____________________________________________________________________________ Cell Phone # ____________________________________________________________________________ Email ____________________________________________________________________________ Tax ID ____________________________________________________________________________ P.O. # ____________________________________________________________________________ ST RFP# ____________________________________________________________________________ Important: The tutoring company is not authorized to begin services and no contract is formed until an authorized District Purchase Order is issued. The district may terminate this contract if Provider does not abide by policies and procedures established by the district and adhere to all state and federal laws. The company will be paid for services rendered prior to termination. The Provider must hold all required licenses; provided a certificate of insurance, and fingerprint clearance cards for each tutor serving the district. Per pupil: For the 2011‐12 school year, the Per Pupil Allocation is $946.00. Cost per authorized pupil may not exceed the Per Pupil Allocation from the start of services to April 1, 2012. Vendor pre & post assessments are the responsibility of the vendor and not an allowable cost.
Business Procedure
1. Vendor Registration and Set‐up
Vendors wishing to provide services to Tolleson Union High School District students must attend a Site Organizational meeting (see vendor fair invitation for meeting date).
Vendors who serve TUHSD students must complete and return the required forms identified in the TUHSD Supplemental Education Services Provider Guidebook Section: Vendor Registration and Set‐up
2. Completing the Supplemental Education Services (SES) Agreement
Only official copies of the ARIZONA DEPARTMENT OF EDUCATION SUPPLEMENTAL EDUCATIONAL SERVICES (SES) AGREEMENT may be used for students in Tolleson Union High School District. Any copies that have been modified from their original form will not be accepted.
The SES Agreement goals for each student must be established prior to the first tutoring session.
All sections of the SES agreement must be completed in full and signed by the parent and vendor representative before submitting it for review by the site representatives.
The total processing time for SES Agreements is fifteen days. The site representatives have 5 school days in which to review and approve the SES Agreements. The approved agreement is submitted to the district office for Purchase Order assignment. Please plan accordingly when scheduling your first tutoring session.
Tutoring services may not be initiated prior to obtaining confirmation of a valid district purchase order for the current fiscal period with the specific student named in the purchase order.
3. Use of School Facilities
Scheduling of facilities must be arranged with the site representative at each school.
All tutors must carry their fingerprint card and identification with the vendor company while at the schools. The vendor must provide the School Improvement Department with evidence of fingerprint cards and/or background checks for every tutor on their roster prior to initiating services.
Only rooms that have been identified in the Lease Permit request may be used by the vendor at the time(s) and day(s) indicated.
Each classroom used by the tutor for instruction must be left in the same condition as it was upon arrival.
Vendors and their tutors may not use classroom supplies.
No keys will be issued to the SES Vendors or their tutors.
The custodial crew is not on call for the vendors or their tutor; however, the custodians will be available for emergency safety issues.
Computer technology in the Tolleson Union High School District is integrated into our District‐wide network. All software programs must undergo extensive review and testing before being used on the TUHSD network. Network security is a high priority; outside provider access would be severely restricted, even if it were to function well. All computer activity must occur under the close scrutiny of our Management Information Systems/Technology Department. Given these limitations and restrictions, TUHSD Supplemental Educational Services (SES) offered via computer may be unable to be provided on the campus or elsewhere in school facilities.
The Vendor acting in accordance with this contract and the services provided to Copper Canyon High School Students with an approved SES Agreement will receive the designation of IN‐KIND COMPENSATION IN LIEU OF FEE PAYMENT as stated in the TUHSD Facilities Use Policy for tutorial services provided on Monday, Tuesday, and Friday (Holidays/ Breaks excluded) that terminate before 5:00 p.m. Therefore, as In‐Kind Compensation in Lieu of Fee Payment the fee for facility use will be
waived (no fee). The In‐kind designation is based upon the coordination, planning, and monitoring services that you will provide throughout the implementation of this contract. However, tutorial services held outside the aforementioned times WILL BE CHARGED based upon the organizational structure for facility use.
Failure to comply with Facility Use Guidelines or Expectations may result in in‐kind compensation in lieu of fee payment status being revoked.
4. Services to Students
In keeping with FERPA regulations, the vendors and their tutors may not disclose any information about any student to anyone outside the school community.
For the safety of our children, all tutors must carry at all times while on campus, their fingerprint card and vendor affiliation and must produce both if asked by any employees on campus.
Services with the students may only begin after: a) A PO has been issued. b) Vendor contracts have been completed and approved. c) Tutor fingerprint cards have been received. NOTE: Fingerprint cards request in process is
NOT an acceptable document. d) SES Agreements have been approved by the site representatives.
Vendors must provide a consistent tutoring schedule for each student and may not start and stop services. Therefore, vendors must provide tutoring services to each student a minimum of one day per week (except during holidays).
Vendors must supply Tolleson Union High School District the tutoring schedule in advance so the schools are made aware of approved tutors scheduled for each campus.
It is the responsibility of the vendor to arrange for substitutes if their teachers are absent.
It is also the vendor’s responsibility to inform all of their students if there are changes to the scheduled learning sessions.
No shows: A “no show” is defined as a student with an approved SES Agreement but has not attended any scheduled tutoring sessions. If the student does not show for the first SES tutoring session, contact the parent and notify them that the student will be dropped if he/she is not present for the next session. If the student does not show for the second SES session, contact the parent and Site Principal that the student is being dropped due to non‐participation. No payments are rendered for “no shows”.
Absences: An “absence” is defined as a student with an approved SES Agreement who has attended at least one tutoring session but has missed a session. After the first absence, the vendor must notify the parent that a second absence will result in the child being dropped from the program. These absences do not have to occur consecutively. The District will pay for up to 2 absences. The only exceptions in the case of a family emergency or health issues that precludes the student from attending. In such instances, vendors must notify the program implementation representative at the site.
Tutors must immediately report to the Site representative and/or Principal if a child appears to be in danger of hurting themselves or others or there is evidence of abuse.
Tutors must ensure that all their students have safely left the campus before leaving themselves.
Complaints or Issues should be reported in writing by completing a Supplemental Education Services (SES) Program Incident Report. This form is available at Copper Canyon High School and on the Arizona Department of Education Website: http://www.ade.state.az.us/asd/title1/SES/.
5. Compensation for Services Rendered
Compensation for services is contingent upon submitting attendance, progress reports, and sign‐ins.
Monthly Invoice & Attendance Sign‐In sheets may be submitted for payment to Tolleson Union High School District – School Improvement Office at 9801 West Van Buren Street, Tolleson, AZ 85353.
Tolleson Union High School District SES Invoices & Attendance Sign‐In sheets signed (NOT initialed) by the student must be submitted with invoices. Invoices submitted without attendance sheets and student signatures will not be processed.
Progress reports are required to be submitted to the parent and the site representative each month. Failure to provide monthly progress reports to parents and site representatives may result in payments being withheld.
Invoices are payable the 10th business day after the receipt providing all required information is submitted and the invoice is in order.
All services must be complete by April 1, 2012. All invoices must be submitted by June 30, 2012 in order to ensure payment prior to closing the books for the year.
Tolleson Union High School District reserves the right to withhold payment if all requisite documentation is not provided as stipulated above.
Checks will be mailed directly to the vendor or to a 3rd party as specified by the vendor.
Signature
Company Name: ______________________________________________________ Authorized Signature (Vendor) ____________________________________ Date: ____________ Print Name: ______________________________________________________ Authorized Signature (District): _____________________________________ Date: ___________ Print Name: ______________________________________________________
Submit this signed contract to the Tolleson Union High School District Office
For School District Only
Approval of Grant Director Business Manager Executive Director ______________________________________ ________________________________________ ________________________________________
AADDMMIINNIISSTTRRAATTIIVVEE CCEENNTTEERR GGOOVVEERRNNIINNGG BBOOAARRDD IINNTTEERRIIMM SSUUPPEERRIINNTTEENNDDEENNTT 9801 West Van Buren Street José Arenas, President Dr. Margo Olivares-Seck Tolleson, Arizona 85353 Alberto Coronado, Jr., Vice President (623) 478-4000 Mike Watson, Member (623) 936-5048 Fax Kimberly A. Owens, Member Website: www.tuhsd.org Freddie Villalon, Member
Tolleson Union High School District Purchasing Department
Phone: 623.478.4005 Fax: 623.478.4197
The Purchasing staff has received a request to add you to the District vendor database. We maintain this computerized list to help our end-users identify competitive products/services required by the District. The list is unique to Tolleson Union High School District and the District is not required to utilize any other vendor list. If you are interested in being included on the District vendor list, please submit the attached Vendor Registration Application. Additionally, if you wish to receive notification when the District releases a Bid and/or Proposal, please complete an online registration with AZ Purchasing as well. You may do so by visiting URL, www.azpurchasing.org. Please note, if you do not register at www.azpurchasing.org, you will not be notified of bids and/or proposals. If you have previously registered with AZ Purchasing, you need only confirm that you have indicated Maricopa County as one of your counties of preference. Per IRS regulations, the District must have a W-9 on file for every vendor. You will not be registered without a W-9 nor will invoices be paid. A copy of the W-9 is available from the IRS website at http://www.irs.gov/pub/irs-pdf/fw9.pdf. The Tolleson Union High School District processes approximately 4,000 purchase orders each school year. We also prepare over 50 formal solicitations and over 50 written quotations. The District is a member of the Greater Phoenix Purchasing Consortium of Schools (GPPCS), the Strategic Alliance of Volume Expenditures (SAVE) and the Arizona State Procurement Office (State Contract). We are always interested in locating outstanding vendors with quality products at competitive prices. We encourage our vendors to provide the Purchasing Department with the latest product literature and catalogs. Or if you would like to schedule an appointment, please contact us.
Sincerely,
Cheryl J. Burt Director of Purchasing
G:\Purchasing\Forms\Vendor Application--New as of 8-20-10.doc
Vendor Registration Application TOLLESON UNION HIGH SCHOOL DISTRICT #214
Purchasing Department 9801 W. Van Buren St., Tolleson, AZ 85353
Fax 623.478.4197
Company Name:_______________________________________________________________________________________ Mailing Address:______________________________________________________________________________________ Street or P.O. Box City State Zip Code Remittance Address:____________________________________________________________________________________ Street or P.O. Box City State Zip Code Business Phone:_________/__________________________ Fax:________/______________________________ Contact Person(s):_____________________________________________ Title:_________________________________ Email Address Bids Can Be Received:_____________________________________________________________________ Website Address:______________________________________________________________________________________ Payment Terms: Net: _____________ Prompt Pay Discount: _____________
What email address should we use to place an order?______________________________________
If you wish to receive notification when the District releases a Bid and/or Proposal, please complete a vendor registration with AZ Purchasing. You may do so by visiting URL, www.azpurchasing.org. If you do not register at www.azpurchasing.org, you will not be notified of bids and/or proposals. If you have previously registered with AZ Purchasing, you need only confirm that you have indicated Maricopa County as one of your counties of preference.
I certify that:
1. I am duly authorized to certify the information requested herein; 2. To the best of my knowledge, the elements of information provided herein are accurate and true as of this date; 3. My organization shall comply with all State and Federal equal opportunity and non-discrimination requirements and conditions of
employment in accordance with Federal Executive Order 11246, State Executive Order 75.5 or A.R.S.41-1461 through 1465; In accordance with A.R.S. § 35-392, the offeror is in compliance and shall remain in compliance with the Export Administration Act. 4. In accordance with A.R.S. § 35-391, the offeror does not have scrutinized business operations in Sudan or Iran. 5. The offeror warrants that it and all proposed subcontractors will maintain compliance with the Federal Immigration and Nationality Act
(FINA), A.R.S. § 41-4401 and A.R.S. § 23-214 and all other Federal immigration laws and regulations related to the immigration status of its employees which requires compliance with Federal immigration laws by employers, contractors and subcontractors in accordance with the E-Verify Employee Eligibility Verification Program.
6. I understand that it’s our responsibility to advise the Purchasing Department in writing of any changes of information (i.e. addresses, contacts, phone/FAX numbers, classification codes, etc.) on this form;
7. My organization shall not provide any product or service without first having in our possession an authorized purchase order from the District. I understand that payment for any product or service provided without an authorized purchase order is NOT the responsibility of the District and that I will be required to obtain payment from the individual requestor;
8. My organization shall provide the purchase order number on all invoices submitted to the District. I understand that invoices received without this information will not be paid;
9. All District invoices shall be submitted directly to the District Accounts Payable Department and not to the requesting school or department.
10. Filing of Vendor Registration Application supplies information only and does not constitute an assumed obligation by Tolleson Union High School District No. 214 to guarantee contractual awards or agreements to my organization.
__________________________________________________________________________________________________ Individual’s Signature Date
__________________________________________________________________________________ Individual’s Typed or Printed Name Title/Position
IRS Regulations require that we have a copy of your W9 on file. Please fax a copy of your W9 form along with your registration
Give form to therequester. Do notsend to the IRS.
Form W-9 Request for TaxpayerIdentification Number and Certification(Rev. January 2003)
Department of the TreasuryInternal Revenue Service
Name
List account number(s) here (optional)
Address (number, street, and apt. or suite no.)
City, state, and ZIP code
Pri
nt o
r ty
pe
See
Sp
ecifi
c In
stru
ctio
ns o
n p
age
2.
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN).However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions onpage 3. For other entities, it is your employer identification number (EIN). If you do not have a number,see How to get a TIN on page 3.
Social security number
––or
Requester’s name and address (optional)
Employer identification numberNote: If the account is in more than one name, see the chart on page 4 for guidelines on whose numberto enter. –
Certification
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the InternalRevenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS hasnotified me that I am no longer subject to backup withholding, and
2.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backupwithholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirementarrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you mustprovide your correct TIN. (See the instructions on page 4.)
SignHere
Signature ofU.S. person � Date �
Purpose of Form
Form W-9 (Rev. 1-2003)
Part I
Part II
Business name, if different from above
Cat. No. 10231X
Check appropriate box:
Under penalties of perjury, I certify that:
U.S. person. Use Form W-9 only if you are a U.S. person(including a resident alien), to provide your correct TIN to theperson requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you arewaiting for a number to be issued),
2. Certify that you are not subject to backup withholding,or
3. Claim exemption from backup withholding if you are aU.S. exempt payee.
Foreign person. If you are a foreign person, use theappropriate Form W-8 (see Pub. 515, Withholding of Tax onNonresident Aliens and Foreign Entities).
3. I am a U.S. person (including a U.S. resident alien).
A person who is required to file an information return withthe IRS, must obtain your correct taxpayer identificationnumber (TIN) to report, for example, income paid to you, realestate transactions, mortgage interest you paid, acquisitionor abandonment of secured property, cancellation of debt, orcontributions you made to an IRA.
Individual/Sole proprietor Corporation Partnership Other �
Exempt from backupwithholding
Note: If a requester gives you a form other than Form W-9to request your TIN, you must use the requester’s form if it issubstantially similar to this Form W-9.
Nonresident alien who becomes a resident alien.Generally, only a nonresident alien individual may use theterms of a tax treaty to reduce or eliminate U.S. tax oncertain types of income. However, most tax treaties contain aprovision known as a “saving clause.” Exceptions specifiedin the saving clause may permit an exemption from tax tocontinue for certain types of income even after the recipienthas otherwise become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on anexception contained in the saving clause of a tax treaty toclaim an exemption from U.S. tax on certain types of income,you must attach a statement that specifies the following fiveitems:
1. The treaty country. Generally, this must be the sametreaty under which you claimed exemption from tax as anonresident alien.
2. The treaty article addressing the income.3. The article number (or location) in the tax treaty that
contains the saving clause and its exceptions.4. The type and amount of income that qualifies for the
exemption from tax.5. Sufficient facts to justify the exemption from tax under
the terms of the treaty article.
Form W-9 (Rev. 1-2003) Page 2
Sole proprietor. Enter your individual name as shown onyour social security card on the “Name” line. You may enteryour business, trade, or “doing business as (DBA)” name onthe “Business name” line.
Other entities. Enter your business name as shown onrequired Federal tax documents on the “Name” line. Thisname should match the name shown on the charter or otherlegal document creating the entity. You may enter anybusiness, trade, or DBA name on the “Business name” line.
If the account is in joint names, list first, and then circle,the name of the person or entity whose number you enteredin Part I of the form.
Limited liability company (LLC). If you are a single-memberLLC (including a foreign LLC with a domestic owner) that isdisregarded as an entity separate from its owner underTreasury regulations section 301.7701-3, enter the owner’sname on the “Name” line. Enter the LLC’s name on the“Business name” line.
Specific Instructions
Name
Exempt From Backup Withholding
Generally, individuals (including sole proprietors) are notexempt from backup withholding. Corporations are exemptfrom backup withholding for certain payments, such asinterest and dividends.
5. You do not certify to the requester that you are notsubject to backup withholding under 4 above (for reportableinterest and dividend accounts opened after 1983 only).
Certain payees and payments are exempt from backupwithholding. See the instructions below and the separateInstructions for the Requester of Form W-9.
Civil penalty for false information with respect towithholding. If you make a false statement with noreasonable basis that results in no backup withholding, youare subject to a $500 penalty.Criminal penalty for falsifying information. Willfullyfalsifying certifications or affirmations may subject you tocriminal penalties including fines and/or imprisonment.
PenaltiesFailure to furnish TIN. If you fail to furnish your correct TINto a requester, you are subject to a penalty of $50 for eachsuch failure unless your failure is due to reasonable causeand not to willful neglect.
Misuse of TINs. If the requester discloses or uses TINs inviolation of Federal law, the requester may be subject to civiland criminal penalties.
If you are an individual, you must generally enter the nameshown on your social security card. However, if you havechanged your last name, for instance, due to marriagewithout informing the Social Security Administration of thename change, enter your first name, the last name shown onyour social security card, and your new last name.
Exempt payees. Backup withholding is not required on anypayments made to the following payees:
1. An organization exempt from tax under section 501(a),any IRA, or a custodial account under section 403(b)(7) if theaccount satisfies the requirements of section 401(f)(2);
2. The United States or any of its agencies orinstrumentalities;
3. A state, the District of Columbia, a possession of theUnited States, or any of their political subdivisions orinstrumentalities;
4. A foreign government or any of its political subdivisions,agencies, or instrumentalities; or
5. An international organization or any of its agencies orinstrumentalities.
Other payees that may be exempt from backupwithholding include:
6. A corporation;7. A foreign central bank of issue;8. A dealer in securities or commodities required to register
in the United States, the District of Columbia, or apossession of the United States;
If you are exempt, enter your name as described above andcheck the appropriate box for your status, then check the“Exempt from backup withholding” box in the line followingthe business name, sign and date the form.
4. The IRS tells you that you are subject to backupwithholding because you did not report all your interest anddividends on your tax return (for reportable interest anddividends only), or
3. The IRS tells the requester that you furnished anincorrect TIN, or
2. You do not certify your TIN when required (see the PartII instructions on page 4 for details), or
You will not be subject to backup withholding on paymentsyou receive if you give the requester your correct TIN, makethe proper certifications, and report all your taxable interestand dividends on your tax return.
1. You do not furnish your TIN to the requester, or
What is backup withholding? Persons making certainpayments to you must under certain conditions withhold andpay to the IRS 30% of such payments (29% after December31, 2003; 28% after December 31, 2005). This is called“backup withholding.” Payments that may be subject tobackup withholding include interest, dividends, broker andbarter exchange transactions, rents, royalties, nonemployeepay, and certain payments from fishing boat operators. Realestate transactions are not subject to backup withholding.
Payments you receive will be subject to backupwithholding if:
If you are a nonresident alien or a foreign entity notsubject to backup withholding, give the requester theappropriate completed Form W-8.
Example. Article 20 of the U.S.-China income tax treatyallows an exemption from tax for scholarship incomereceived by a Chinese student temporarily present in theUnited States. Under U.S. law, this student will become aresident alien for tax purposes if his or her stay in the UnitedStates exceeds 5 calendar years. However, paragraph 2 ofthe first Protocol to the U.S.-China treaty (dated April 30,1984) allows the provisions of Article 20 to continue to applyeven after the Chinese student becomes a resident alien ofthe United States. A Chinese student who qualifies for thisexception (under paragraph 2 of the first protocol) and isrelying on this exception to claim an exemption from tax onhis or her scholarship or fellowship income would attach toForm W-9 a statement that includes the informationdescribed above to support that exemption.
Note: You are requested to check the appropr iate box foryour status (individual/sole propr ietor, corporation, etc. ).
Note: If you are exempt from backup withholding, you shouldstill complete this form to avoid possible erroneous backupwithholding.
Form W-9 (Rev. 1-2003) Page 3
Part I. Taxpayer IdentificationNumber (TIN)Enter your TIN in the appropriate box. If you are a residentalien and you do not have and are not eligible to get anSSN, your TIN is your IRS individual taxpayer identificationnumber (ITIN). Enter it in the social security number box. Ifyou do not have an ITIN, see How to get a TIN below.
How to get a TIN. If you do not have a TIN, apply for oneimmediately. To apply for an SSN, get Form SS-5,Application for a Social Security Card, from your local SocialSecurity Administration office or get this form on-line atwww.ssa.gov/online/ss5.html. You may also get this formby calling 1-800-772-1213. Use Form W-7, Application forIRS Individual Taxpayer Identification Number, to apply for anITIN, or Form SS-4, Application for Employer IdentificationNumber, to apply for an EIN. You can get Forms W-7 andSS-4 from the IRS by calling 1-800-TAX-FORM(1-800-829-3676) or from the IRS Web Site at www.irs.gov.
If you are asked to complete Form W-9 but do not have aTIN, write “Applied For” in the space for the TIN, sign anddate the form, and give it to the requester. For interest anddividend payments, and certain payments made with respectto readily tradable instruments, generally you will have 60days to get a TIN and give it to the requester before you aresubject to backup withholding on payments. The 60-day ruledoes not apply to other types of payments. You will besubject to backup withholding on all such payments until youprovide your TIN to the requester.
If you are a sole proprietor and you have an EIN, you mayenter either your SSN or EIN. However, the IRS prefers thatyou use your SSN.
If you are a single-owner LLC that is disregarded as anentity separate from its owner (see Limited liabilitycompany (LLC) on page 2), enter your SSN (or EIN, if youhave one). If the LLC is a corporation, partnership, etc., enterthe entity’s EIN.Note: See the chart on page 4 for further clar ification ofname and TIN combinations.
Note: Writing “Applied For” means that you have alreadyapplied for a TIN or that you intend to apply for one soon.Caution: A disregarded domestic entity that has a foreignowner must use the appropr iate Form W-8.
9. A futures commission merchant registered with theCommodity Futures Trading Commission;
10. A real estate investment trust;11. An entity registered at all times during the tax year
under the Investment Company Act of 1940;12. A common trust fund operated by a bank under
section 584(a);13. A financial institution;14. A middleman known in the investment community as a
nominee or custodian; or15. A trust exempt from tax under section 664 or
described in section 4947.
THEN the payment is exemptfor . . .
If the payment is for . . .
All exempt recipients except for 9
Interest and dividend payments
Exempt recipients 1 through 13.Also, a person registered underthe Investment Advisers Act of1940 who regularly acts as abroker
Broker transactions
Exempt recipients 1 through 5Barter exchange transactionsand patronage dividends
Generally, exempt recipients1 through 7 2
Payments over $600 requiredto be reported and directsales over $5,000 1
1 See Form 1099-MISC, Miscellaneous Income, and its instructions.2 However, the following payments made to a corporation (including grossproceeds paid to an attorney under section 6045(f), even if the attorney is acorporation) and reportable on Form 1099-MISC are not exempt from backupwithholding: medical and health care payments, attorneys’ fees; and paymentsfor services paid by a Federal executive agency.
The chart below shows types of payments that may beexempt from backup withholding. The chart applies to theexempt recipients listed above, 1 through 15.
Form W-9 (Rev. 1-2003) Page 4
What Name and Number To Give theRequester
Give name and SSN of:For this type of account:
The individual1. Individual
The actual owner of the accountor, if combined funds, the firstindividual on the account 1
2. Two or more individuals (jointaccount)
The minor 23. Custodian account of a minor(Uniform Gift to Minors Act)
The grantor-trustee 14. a. The usual revocablesavings trust (grantor isalso trustee)
1. Interest, dividend, and barter exchange accountsopened before 1984 and broker accounts consideredactive during 1983. You must give your correct TIN, but youdo not have to sign the certification.
The actual owner 1b. So-called trust accountthat is not a legal or validtrust under state law2. Interest, dividend, broker, and barter exchange
accounts opened after 1983 and broker accountsconsidered inactive during 1983. You must sign thecertification or backup withholding will apply. If you aresubject to backup withholding and you are merely providingyour correct TIN to the requester, you must cross out item 2in the certification before signing the form.
The owner 35. Sole proprietorship orsingle-owner LLC
Give name and EIN of:For this type of account:
3. Real estate transactions. You must sign thecertification. You may cross out item 2 of the certification.
A valid trust, estate, orpension trust
6.
Legal entity 4
4. Other payments. You must give your correct TIN, butyou do not have to sign the certification unless you havebeen notified that you have previously given an incorrect TIN.“Other payments” include payments made in the course ofthe requester’s trade or business for rents, royalties, goods(other than bills for merchandise), medical and health careservices (including payments to corporations), payments to anonemployee for services, payments to certain fishing boatcrew members and fishermen, and gross proceeds paid toattorneys (including payments to corporations).
The corporationCorporate or LLC electingcorporate status on Form8832
7.
The organizationAssociation, club, religious,charitable, educational, orother tax-exempt organization
8.
5. Mortgage interest paid by you, acquisition orabandonment of secured property, cancellation of debt,qualified tuition program payments (under section 529),IRA or Archer MSA contributions or distributions, andpension distributions. You must give your correct TIN, butyou do not have to sign the certification.
The partnershipPartnership or multi-memberLLC
9.
The broker or nomineeA broker or registerednominee
10.
The public entityAccount with the Departmentof Agriculture in the name ofa public entity (such as astate or local government,school district, or prison) thatreceives agricultural programpayments
11.
Privacy Act Notice
1 List first and circle the name of the person whose number you furnish. If onlyone person on a joint account has an SSN, that person’s number must befurnished.2 Circle the minor’s name and furnish the minor’s SSN.3 You must show your individual name, but you may also enter yourbusiness or “DBA” name. You may use either your SSN or EIN (if you haveone).4 List first and circle the name of the legal trust, estate, or pension trust. (Donot furnish the TIN of the personal representative or trustee unless the legalentity itself is not designated in the account title.)
Note: If no name is circled when more than one name islisted, the number will be considered to be that of the firstname listed.
Sole proprietorship orsingle-owner LLC
The owner 3
12.
Part II. Certification
For a joint account, only the person whose TIN is shown inPart I should sign (when required). Exempt recipients, seeExempt from backup withholding on page 2.
You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 30% of taxableinterest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
To establish to the withholding agent that you are a U.S.person, or resident alien, sign Form W-9. You may berequested to sign by the withholding agent even if items 1, 3,and 5 below indicate otherwise.
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returnswith the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition orabandonment of secured property, cancellation of debt, or contributions you made to an IRA or Archer MSA. The IRS uses thenumbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this informationto the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out theirtax laws. We may also disclose this information to other countries under a tax treaty, or to Federal and state agencies to enforceFederal nontax criminal laws and to combat terrorism.
Signature requirements. Complete the certification asindicated in 1 through 5 below.
Arizona Department of Education (ADE) Supplemental Educational Services (SES)
Canvassing Agreement
Provider: Promotional Materials approved? Y / N
Signature: _______________________________________
Some background information: Statistics: In 2008-09, approximately 6,000 out of a total of 39,000 eligible student slots were filled. This equates to approximately 15% of our eligible students. Parents may be reluctant to attend school functions and, therefore, may not have a real opportunity to learn about SES.
What is canvassing?
Door-to-door and public venue solicitation with face-to-face interaction by approved SES providers.
Who can canvass?
Employees and contractors of providers: Employees must be at least 18 years of age, and providers must verify I-9 documentation
and E-verify. All canvassers must be W-2 employee or 1099 contractors with W-9 information on file. Canvassers cannot be students receiving SES services. Canvassers must have full background/criminal checks performed by an accredited
agency. Fingerprint cards meet this requirement. Canvassers must be trained on SES, their company, and safety guidelines. Providers are responsible for the actions of their canvassers. The burden of proof lies with the provider to ensure proper canvassing and the LEA may
choose to re-assign students if any activities are deemed questionable. Canvassers and providers will adhere to the of Professional Conduct and Business
Ethics for Supplemental Educational Services (SES) Providers posted on the ADE website at http://www.ade.az.gov/asd/Title1/SES/.
What materials and information do canvassers need?
Canvassing cannot commence before the Parent Notification letter is sent out. Check with the LEA regarding canvassing for summer programs.
Promotional materials used in canvassing must be approved by ADE and made available to LEAs. Materials should be written in English and Spanish.
Providers must notify the LEA SES Coordinator of all canvassing activities and designate specifically which neighborhoods and public sites will be included.
Providers may ask (not demand) LEAs for a map of eligible attendance areas. Canvassers should be prepared to reassure parents that canvassing is done randomly
and that the school did not distribute directory information, if applicable. In some cases, the LEA will have provided such information. Providers who have previously served families may also already have directory information.
Providers must seek permission from the building principal before canvassing on-site. Canvassing at a school should not occur during busy times like the start and end of the school day. Canvassing at a school or school event requires permission from the principal. This includes leaving information with school personnel.
Providers should use the LEA’s SES Application and may need to add canvassing details to it.
a) The LEA’s SES Application must include the same information as the generic example available on ADE SES website.
b) LEA Applications should be customized to include specific information such as the schools involved and LEA/school contact information.
c) Applications used for canvassing should be coded for tracking. d) Applications must include a space for canvassers to identify themselves and
the provider for whom they work. e) Providers may choose to keep a log of the families they have contacted.
Providers may follow up with LEAs to see if SES Applications have been returned to the LEA and processed.
f) Applications must include a space for the LEA SES contact name and number with instructions to call with any complaints.
Canvassers must have the complete list of approved providers for the LEA’s attendance area. The list must include a brief description of each provider.
Canvassers must instruct parents to choose 3 providers. Do not pre-populate! Applications not completed correctly may be voided by the LEA.
Canvassers must remind parents that the LEA will determine eligibility for the SES program.
Canvassers must remind parents to return the Application to the LEA/school. Under no circumstances are providers allowed to collect or return Applications.
Canvassers cannot promise a set number of hours of tutoring. Provider flyers to be used in canvassing must be approved by the state and must be
available to LEAs. The flyers must include a “complaint” phone number to be used by parents and other stakeholders.
Canvassers must be easily identified as an employee (agent) of the provider. For example, canvassers should wear a name badge or company shirt.
All canvassing will cease at dusk. Under no circumstances should a canvasser enter the premises, even if invited in.
Direct mailings
Providers are allowed to contact previous customers. In this case, the SES Application
must still include three choices of providers. As always the SES Application must be
returned to the school by the parent, not the provider.
Tolleson Union High School District #214
FACILITY USE AGREEMENT
Today’s Date: ________________________________________________ FOR USE OF FACILITIES LOCATED AT: ________________________________________________ Tolleson Union High School District, Maricopa County, lessor, hereby agrees to lease: Specific Facility to be Used: _____________________________ Lessor Contact Person: _____________________________ Phone: ____________
TO: Name of Lessee or Organization: _____________________________ Lessee Contact Person: _____________________ Phone: ____________
Mailing Address of Lessee or Organization: __________________________________________________________________________________
The following terms and conditions apply to the use and rental of all facilities: (please read before signing) 1. The premises are to be used only for the expressed purposes as identified in the application. 2. No smoking or alcoholic beverages are to be allowed. 3. District staff is to have access to all facilities at all times. 4. All properties and equipment are to be accounted for and left in the same condition, taking into account normal wear, as they were at the time of use. 5. No lighting, wiring, or scenery is to be changed except by special permission from the building administrator. 6. Any program of speakers, plays, or presentations must be submitted for approval at the time the rental application is received. 7. Any advertising for the promotion of the program must indicate the sponsoring agent. 8. This District reserves the right to refund deposits paid in advance for rental of any facilities should the building principal or superintendent decide the usage is
not in the best interests of the District. 9. Liability insurance shall be provided by the renter and evidence of same (satisfactory to the District) shall be filed at the time of application. This insurance
shall be provided in the minimum limits of $1,000,000 combined single limit for bodily injuries and property damage. The applicant agrees to name the District as an “additional insured” on the applicant’s liability policy as respects the use of District property.
10. Applicant agrees to comply with all federal, state, and municipal laws, rules, ordinances, regulations, and orders with respect to the sue and occupancy thereof. Applicant, during the term of this permit, covenants and agrees to indemnify and hold harmless the District from each and every loss, cost, damage and expense arising out of any accident or other occurrence causing injury to or death of persons or damage to property due to the conditions of the rented premises or the use or neglect thereof by the renter.
11. Renter agrees that it will pay for any unusual wear, tear, breakage, and damage to facility occurring from the use of the facility or equipment. Should a facility or equipment be damaged the renter agrees to reimburse the District for the full cost of repair or replacement. The renter agrees to provide any necessary security and/or maintenance personnel as required by the District. These services can be purchased through the District.
12. The applicant shall observe all safety and parking guidelines. The applicant shall not allow any parking in areas identified as fire lanes.
USAGE Purpose: _____________________________________________________________ Date(s): ________________________________________ Time: _____________________________________________________________ To: _____________________________________________ Special equipment needed:
RENT IS PAYABLE IN ADVANCE. It is understood that all rates quoted, as well as other conditions stipulated, are a part of this agreement.
BASE CHARGE OF FACILITY TO BE USED: _______________________________________________ ADDITIONAL CHARGES: Utility _______________________ Custodial _______________________ _______________________ _______________________ Make check payable to Tolleson Union High School District (_______________________)
This agreement is accepted upon the foregoing terms and conditions. Please sign and return all copies to the district office at: _________________
NOTE: THIS AGREEMENT IS NOT VALID AND FACILITIES WILL NOT BE MADE AVAILABLE UNTIL SIGNED BY THE PRINCIPAL OR ASSISTANT PRINCIPAL IN CHARGE OF FACILITIES AND A CERTIFICATE OF INSURANCE IS FILED WITH SAME.
For Lessor: Tolleson Union High School District No. 214 For Lessee : _____________________________________________ Name of Lessee or Organization
By: _________________________________________ By: _____________________________________________________ Signature & Title
Insurance Certificate Received ____________________ Fee Waiver Approval _______________________________________ Expiration Date Superintendent or Designee
IN-KIND COMPENSATION IN LIEU OF FEE PAYMENT
Name of Lessee or Organization:__________________________ agrees to the following IN-KIND compensation in lieu of the required fees as set forth in the fee schedule. All In-Kind Compensation agreements must have a value determined by the lessee or Organization which is agreed to by the Tolleson Union High School District #214 Business Office before the contract can be approved. The method for determining value will be based upon established market price, trade in value, posted prices, or appraisal. Required Fee based on the assigned category:______________________ Fair Market Value of IN-KIND compensation: _______________________ Method for determining Value: _________________________________________________ Summary of the IN-KIND compensation:________________________________________________________________________________________
____________________________ ___________________________ ___________________________ Name of Lessee or Organization TUHSD Business Office Superintendent or Designee ___________________________ ___________________________ ___________________________ Date Date Date
August 2011
DIRECTIONS: Please complete the application for Free Tutoring (SES) with all necessary information. Sign and
return the form to your school or district office. The school will contact you once your eligibility has been verified.
Tutoring companies are not permitted to accept or carry in these forms for you. Use one form per child.
Application for Supplemental Educational (SES)
2011-2012 School Year Supplemental Educational Services are free tutoring services provided by tutoring companies approved by the Arizona
Department of Education under the current Title I ESEA law. Parents of children from eligible schools have the
opportunity to apply for these services at no charge to them.
Name of Student __________________________________________ Date of Birth______________________
Address ________________________________________________________ ZIP____________________
Phone ____________________________________Current Grade in school____________________________
Name of School District_____________________________________________________________________
Name of School student currently attends_______________________________________________________
My child needs tutoring in: Reading OR Math
Select an Approved Provider from the attached list. Information about all vendors may be found on the
ADE SES website. Please list your choice of SES Approved Provider:
1st choice______________________________________________________________________
2nd
choice______________________________________________________________________
3rd
choice______________________________________________________________________
Parent gives permission to the district to release the child’s school records, upon acceptance into the
program, for the purpose of creating a student learning plan as part of the SES Agreement with the School,
the Provider and the Parent.
Parent /Guardian Name – PRINT: __________________________________________________________
Parent/Guardian Signature: ______________________________________________________________
The provider has explained in the event their tutoring class is full to capacity that I have the option of starting
services for my child immediately by selecting my next provider choice or waiting until a slot becomes
available to start tutoring for my child. If the class size is full, I choose to:
Move my child to the next provider choice(s) until a slot is located for my child
Stay with this provider and wait until the next session of tutoring to begin services for my child
The provider has explained that I have the option of choosing any vendor from the AZ Department of
Education’s Approved Provider List and the Provider has delivered a copy of the Approved Provider list to me.
I have not been promised anything for signing up with this provider.
Parent/Guardian Signature: __________________________________________Date: ___________________
Compañía de Tutoría: _______________________________ Representante:_________________________________ Numero de Rastreo:__________________ August 2011
DIRECCONES: Por favor, complete la aplicación para Tutoría Gratuita (SES) con toda información necesaria. Firme y
entregue la forma a la oficina de la escuela o el distrito. La escuela se pondrá en contacto con usted en cuanto su
elegibilidad a sido verificada. Las compañías de Tutoría no son permitidas aceptar o llevar estas formas por usted.
Use una forma por niño/a.
Aplicación para Educación Suplementarios (SES)
Año Escolar 2011-2012
Servicios de Educación Suplementarios son servicios de tutoría gratuita proveía por compañías de tutoría aprobados por el Departamento de
Educación en Arizona bajo la ley corriente ESEA de Titulo I. Padres de niños en escuelas elegibles tienen la oportunidad para aplicar por estos
servicios a ningún costo a ellos en las siguientes escuelas participantes: ______________________________________________________________
________________________________________________________________________________________________________________________
Nombre del Estudiante ____________________________________ Fecha de Nacimiento_____________________
Domicilio _______________________________________________ Código Postal________________________
Teléfono _______________________________Grado Actual en la Escuela_________________________________
Nombre del Dístrito Escolar_______________________________________________________________________
Nombre de la Escuela que el estudiante asiste _______________________________________________________
Mi hijo/a necesita tutoría en: Lectura Matemáticas
Seleccione un Proveedor Aprobado de la lista adjunta. Información sobre todos los Proveedores puede ser encontrada
en la página de Internet ADE SES.
Debe elegir 3 Proveedores Aprobados SES:
1a selección ______________________________________________________________________
2a selección ______________________________________________________________________
3a selección ______________________________________________________________________
Uno de los padres da permiso al dístrito para liberar el archivo escolar del estudiante al ser aceptado al programa, para el
propósito de crear un plan de aprendizaje para el estudiante como parte del Acuerdo SES con la escuela, el Proveedor y uno
de los padres.
Nombre de uno de los Padres/Guardián – MOLDE __________________________________________________
Firma de uno de los Padres/Guardián _______________________________________________________
El proveedor ha explicado que en el evento que sus clases de tutoría se llenan hasta su capacidad máxima yo tengo la
opción de empezar los servicios de tutoría para mi hijo/a inmediatamente, seleccionando a mi próxima opción de
proveedor o esperar hasta que este un espacio disponible para empezar la tutoría para mi hijo/a. Si la clase está llena hasta
la capacidad máxima, yo elijo:
Mover a mi hijo/a a mi próxima opción de proveedor(es) hasta que un espacio esté disponible para mi hijo/a
Quedarme con este proveedor y esperar hasta la próxima sesión de tutoría para comenzar los servicios de mi hijo/a
El proveedor me a explicado que tengo la opción de elegir cualquier Proveedores de la Lista Aprobada por el
Departamento de Educación de Arizona y el proveedor me a entregado una copia de la lista de Proveedores Aprobados a
mí. No se me ha prometido nada al firmar con este proveedor.
Firma de uno de los Padres/Guardián __________________________________________ Fecha ___________________
Si tiene alguna pregunta o queja por favor comuníquese con _________________al número _____________________.
:SC
HO
OL
(Esc
uela
):
ecen
fuer
a de
l y
debe
b es
tar
red
to th
is st
uden
t to
incr
ease
his
/her
aca
dem
ic a
chie
vem
ent.
Thes
e se
rvic
es a
re o
ffer
ed
hey
mus
t be
cons
iste
nt w
ith th
e co
nten
t and
inst
ruct
ion
used
by
the
LEA
and
alig
ned
with
DEP
ARTA
MEN
TOD
EED
UC
ACIÓ
ND
EAR
IZO
NA
Acue
rdo
De
Serv
icio
s Edu
cativ
os S
uple
men
tale
s(SE
S)
(Año
Esc
olar
)
gate
(Nom
bre
de P
adre
/Mad
re/S
ustit
uto
Educ
ativ
o):
Tele
phon
e(Te
léfo
no)
:
AZ
(Cód
igo
Post
al):
City
(Ciu
dad)
:):
SUPP
LE
ME
NT
AL
ED
UC
AT
ION
AL
SER
VIC
ES-
Stat
e(E
stad
o):
ip C
ode:
(ES)
(ElP
adre
/La
Mad
re/S
ustit
uto
Educ
ativ
o)
:*
Ethn
icity
(Étn
ico*
):- U
se c
ode
from
bac
k co
ver
):
AZ
City
(Ciu
dad)
:
(Res
pons
abili
dade
s del
Pad
re/M
adre
/Tut
or/S
ustit
uo E
duca
tivo)
:
(Cód
igo
Post
al):
Tele
phon
e(Te
léfo
no):
Stat
e(E
stad
o):
ip C
ode:
Gen
der:
Gen
ero:
Ethn
icity
:*
Étni
co*
(Nom
bre
del E
stud
iant
e):
The
Pare
nt/G
uard
ian
/Edu
catio
nalS
urro
gate
(ES)
(ElP
adre
/La
Mad
re/S
ustit
uto
Educ
ativ
o)In
itial
s of P
aren
t /
Gua
rdia
n / E
S
(Ini
cial
es d
el p
adre
/ m
adre
/ su
stitu
to
educ
ativ
o)
Tele
phon
e(Te
léfo
no):
Luga
r en
la T
utor
ía (p
ropo
rcio
ne la
dir
ecci
ón c
on e
xcep
ción
si e
s la
escu
ela)
:
Acta
de
Gar
antía
sG
aran
tiza
que
el e
stud
iant
e es
tará
pre
sent
e pa
ra re
cibi
er lo
s se
rvic
ios;
que
las n
eces
idad
es e
spec
iale
s del
est
udia
nte
han
sido
com
unic
adas
al p
rove
edor
; est
á de
acu
erdo
en
part
icip
ar
en acue
rdo
en re
visa
r los
repo
rtes
de
prog
reso
con
el e
stud
iant
e.
Prov
ider
Con
tact
(C
onta
cto
de P
rove
edor
):
(IN
FO
RM
AC
IÓN
GE
NE
RA
L D
E P
RO
VE
ED
OR
/TU
TOR
):(N
ombr
e de
la C
ompa
nía)
:
05
Dat
e Si
gned
(F
echa
de
Firm
a)
Prin
t Nam
e of
Stu
dent
(Nom
bre
del E
stud
iant
e Im
prim
ido)
DO
CU
MEN
TTO
DIS
TRIC
T/L
EAO
FFIC
E(E
S)Ed
ilS
Prin
t Nam
e of
P /
G /
ES (N
ombr
e de
l P/M
/SE
Impr
imid
o)
SIG
NA
TU
RE
S (F
irm
as):
Dat
e Si
gned
(F
echa
de
Firm
a)
Prin
t Nam
e of
LEA
Off
icia
l (N
ombr
e de
l Ofic
ial d
el L
EA
Dat
e Si
gned
(F
echa
de
Firm
a)Pr
int N
ame
of P
rovi
der (
Nom
bre
del P
rove
edor
Impr
imid
o)
Dat
e Si
gned
(F
echa
de
Firm
a)
(ES)
= E
duca
tiona
l Sur
roga
te
____
____
____
____
___
ZZ
……
por l
o m
enos
una
(1) r
euni
ón c
on e
l pro
veed
or; y
est
á de
VII
: SC
HO
OL
DIS
TR
ICT
/ L
EA
a la
n
onsi
s
,
guag
e th
e lo
tent
with
p
AR
IZO
NA
DE
PAR
TM
EN
T O
F E
DU
CA
TIO
NTh
e Sc
hool
Dis
tric
t her
eby
gran
ts p
erm
issi
on, P
ER S
EPAR
ATE
AGRE
EMEN
T, to
ven
dor t
o us
e th
e fo
llow
ing
iden
tifie
d fa
cilit
ies:
SUPP
LE
ME
NT
AL
ED
UC
AT
ION
AL
SE
RV
ICE
S (S
ES)
AG
RE
EM
EN
TFA
CIL
ITY
:SC
HO
OL
YE
AR
SP
ECIF
IC L
OC
ATI
ON
:
RO
OM
NU
MB
ER(s
):H
OU
RS
OF
OPE
RA
TIO
N:
The
tuto
ring
serv
ices
are
bei
ng o
fou
tsid
e of
the
regu
lar s
choo
l day
.A
rizon
a St
ate
Aca
dem
ic S
tand
ardfe T s.
DIS
TRIC
T C
ON
TAC
T:TE
LEPH
ON
E N
UM
BER
: (L
os se
rvic
ios t
utor
iale
s se
está
n of
reci
endo
a e
ste
estu
dian
te p
ara
aum
enta
r su
rend
imie
nto
acad
émic
o. E
stos
serv
icio
s se
ofr
día
regu
lar d
e la
esc
uela
. Los
serv
icio
s deb
en se
r con
sist
ente
s con
el c
onte
nido
y la
inst
rucc
ión
usad
os p
or e
l LEA
(Dis
trito
) al
inea
dos c
on lo
s Est
ánda
res A
cadé
mic
os d
el E
stad
o de
Ari
zona
.)T
ITL
E 1
- PA
RT
AIm
prov
ing
Bas
ic P
rogr
ams O
pera
ted
by L
ocal
Edu
catio
nal A
genc
ies (
LE
A)
SEC
. 111
6 (e
)D
IST
RIC
T /
LE
A(D
istr
ito/L
EA)
SUPP
LE
ME
NT
AL
ED
UC
AT
ION
AL
SER
VIC
ES-
(1) S
UPP
LEM
ENTA
L ED
UC
ATI
ON
AL
SER
VIC
ES–
In th
e ca
se o
f any
scho
ol d
escr
ibed
in p
arag
raph
(5),
(7),
or (8
) of s
ubse
ctio
n (b
), th
esu
bjec
t to
this
subs
ectio
n, a
rran
ge fo
r the
pro
visi
on o
f sup
plem
enta
l edu
catio
nal s
ervi
ces t
o el
igib
le c
hild
ren
in th
e sc
hool
from
a p
rovi
der w
ith a
dem
onst
rate
d re
cord
of e
ffec
tiven
ess,
that
is
sele
cted
by
the
pare
nts a
nd a
ppro
ved
for t
hat p
urpo
se b
y th
e St
ate
educ
atio
nal a
genc
y in
acc
orda
nce
with
reas
onab
le c
riter
ia, c
shal
l ado
pt.
cal e
duca
tiona
l age
ncy
serv
ing
such
scho
ol sh
all,
I. ST
UD
EN
T IN
FOR
MA
TIO
N (I
nfor
mac
ión
Del
Est
udia
nte)
arag
raph
(5),
that
the
Stat
e ed
ucat
iona
l age
ncy
SAIS
#:
Gra
Stud
ent's
Nam
ede
:
(2) L
OC
AL
ED
UC
AT
ION
AL
AG
EN
CY
RE
SPO
NSI
BIL
ITIE
S- E
ach
loca
l edu
catio
nal a
genc
y su
bjec
t to
this
subs
ectio
n sh
all—
(A) p
rovi
de, a
t a m
inim
um, a
nnua
l not
ice
to p
aren
ts (i
n an
und
erst
anda
ble
and
unifo
rm fo
rmat
and
, to
the
exte
nt p
ract
icab
le, i
n(i)
the
avai
labi
lity
of se
rvic
es u
nder
this
subs
ectio
n;(ii
) the
iden
tity
of a
ppro
ved
prov
ider
s of t
hose
serv
ices
that
are
with
in th
e lo
cal e
duca
tiona
l age
ncy
or w
hose
serv
ices
are
reas
onab
ly a
vaila
ble
in n
eigh
borin
g lo
cal e
duca
tiona
l age
ncie
s; a
nd(ii
i) a
brie
f des
crip
tion
of th
e se
rvic
es, q
ualif
icat
ions
, and
dem
onst
rate
d ef
fect
iven
ess o
f eac
h su
ch p
rovi
der;
(B) i
f req
uest
ed, a
ssis
t par
ents
in c
hoos
ing
a pr
ovid
er fr
om th
e lis
t of a
ppro
ved
prov
ider
s mai
ntai
ned
by th
e St
ate;
(C) a
pply
fair
and
equi
tabl
e pr
oced
ures
for s
ervi
ng st
uden
ts if
the
num
ber o
f spa
ces a
t app
rove
d pr
ovid
ers i
s not
suff
icie
nt to
serv
e al
l stu
dent
s; a
nd(D
) not
dis
clos
e to
the
publ
ic th
e id
entit
y of
any
stud
ent w
ho is
elig
ible
for,
or re
ceiv
ing,
supp
lem
enta
l edu
catio
nal s
ervi
ces u
nder
this
subs
ectio
n w
ithou
t the
writ
ten
perm
issi
on o
f the
par
ents
of
the
stud
ent.
pare
nts c
an u
nder
stan
d) o
f—G
rado
Stud
ent's
Add
ress
(Dom
icili
ode
l Est
udia
nte
Nam
e of
Par
ent /
Gua
rdia
n / E
duca
tiona
l Sur
ro
(3) A
GR
EE
ME
NT
– In
the
case
of t
he se
lect
ion
of a
n ap
prov
ed p
rovi
der b
y a
pare
nt, t
he lo
cal e
duca
tiona
l age
ncy
shal
l ent
er in
to a
n ag
reem
ent w
(A) r
equi
re th
e lo
cal e
duca
tiona
l age
ncy
to d
evel
op, i
n co
nsul
tatio
n w
ith p
aren
ts (a
nd th
e pr
ovid
er c
hose
n by
the
pare
nts)
, a st
atem
ent o
f spe
cific
ach
ieve
men
t goa
ls fo
r the
stud
ent,
how
the
stud
ent's
pro
gres
s will
be
mea
sure
d, a
nd a
tim
etab
le fo
r im
prov
ing
achi
evem
ent t
hat,
in th
e ca
se o
f a st
uden
t with
dis
abili
ties,
is c
onsi
sten
t with
the
stud
ent's
indi
vidu
aliz
ed e
duca
tion
prog
ram
un
der s
ectio
n 61
4(d)
of t
he In
divi
dual
s with
Dis
abili
ties E
duca
tion
Act
;(B
) des
crib
e ho
w th
e st
uden
t's p
aren
ts a
nd th
e st
uden
t's te
ache
r or t
each
ers w
ill b
e re
gula
rly in
form
ed o
f the
stud
ent's
pro
gres
s;(C
) pro
vide
for t
he te
rmin
atio
n of
such
agr
eem
ent i
f the
pro
vide
r is u
nabl
e to
mee
t suc
h go
als a
nd ti
met
able
s;(
)pg
pg
(D) c
onta
in p
rovi
sion
s with
resp
ect t
o th
e m
akin
g of
pay
men
ts to
the
prov
ider
by
the
loca
l edu
catio
nal a
genc
y; a
nd(E
) pro
hibi
t the
pro
vide
r fro
m d
iscl
osin
g to
the
publ
ic th
e id
entit
y of
any
stud
ent e
ligib
le fo
r, or
rece
ivin
g, su
pple
men
tal e
duca
tiona
l ser
vice
s und
er th
is su
bsec
tion
with
out t
he w
ritte
n pe
rmis
sion
of t
he p
aren
ts o
f suc
h st
uden
t.
ith su
ch p
rovi
der.
Such
agr
eem
ent s
hall—
Add
ress
of P
aren
t / G
uard
ian
/ E S
(Dom
icili
o de
Pad
re/M
adre
/Sus
titut
o Ed
ucat
ivo
II. P
AR
EN
T /
GU
AR
DIA
N /
ES
RE
SPO
NSI
BIL
ITIE
S:
The
Pare
nt/G
uard
ian
/Edu
catio
nalS
urro
gate
Stat
emen
t of A
ssur
ance
s……
Ass
ures
that
the
stud
ent w
ill b
e pr
esen
t for
serv
ices
; tha
t the
sp
ecia
l nee
ds o
f the
stud
ent h
ave
been
com
mun
icat
ed to
the
prov
ider
; ag
rees
to p
artic
ipat
e in
at l
east
one
(1) m
eetin
g w
ith th
e pr
ovid
er; a
nd a
gree
s to
revi
ew p
rogr
ess r
epor
ts w
ith
the
child
.
ET
HN
ICIT
Y C
OD
ES:
01A
mer
ican
Indi
an o
r Ala
skan
Nat
ive-
-A p
erso
n ha
ving
orig
ins i
n an
y of
the
orig
inal
peo
ples
of N
orth
Am
eric
a, a
nd w
ho m
aint
ains
cu
ltura
l ide
ntifi
catio
n th
roug
h tri
bal a
ffili
atio
n or
com
mun
ity re
cogn
ition
. II
I. PR
OV
IDE
R /
TU
TO
R G
EN
ER
AL
INFO
RM
AT
ION
02A
sian
or P
acifi
c Is
land
er--
A p
erso
n ha
ving
orig
ins i
n an
y of
the
orig
inal
peo
ples
of t
he F
ar E
ast,
Sout
heas
t Asi
a, th
e In
dian
su
bcon
tinen
t, or
the
Paci
fic Is
land
s. Th
is a
rea
incl
udes
, for
exa
mpl
e, C
hina
, Ind
ia, J
apan
, Kor
ea, t
he P
hilip
pine
Isla
nds,
and
Tuto
ring
Prov
ider
(Nam
e of
Com
pany
)Pr
ovee
dor d
e Tu
torí
aSa
moa
.
03B
lack
(not
His
pani
c)--
A p
erso
n ha
ving
orig
ins i
n an
y of
the
blac
k ra
cial
gro
ups o
f Afr
ica.
E-
Mai
l(C
orre
o El
ectr
ónic
o):
04H
ispa
nic-
-A p
erso
n of
Mex
ican
, Pue
rto R
ican
, Cub
an, C
entra
l or S
outh
Am
eric
an o
r oth
er S
pani
sh c
ultu
re o
r orig
in, r
egar
dles
s oLo
catio
n of
Tut
orin
g (p
rovi
de a
ddre
ss if
oth
er th
an th
e sc
hool
)f r
ace.
05W
hite
(not
His
pani
c)--
A p
erso
n ha
ving
orig
ins i
n an
y of
the
orig
inal
peo
ples
of E
urop
e, N
orth
Afr
ica,
or t
he M
iddl
e Ea
st.
(p
)p
gg
yg
pp
pA
ssig
ned
Tuto
r(s)
(Tut
or(e
s) A
sign
ado(
s)):
,g
()
((
)g
())
We
here
by c
ertif
y th
at w
e ha
ve re
ad a
nd u
nder
stoo
d th
is S
ES S
ervi
ces A
gree
men
t for
Tut
orin
g(C
ertif
ícam
os q
ue h
emos
leíd
o y
hem
os e
nten
dido
est
e Ac
uerd
o de
Ser
vici
os S
ES p
ara
Tuto
ría)
:SE
RV
ICE
S B
EG
IN U
PON
LE
A F
INA
L A
PPR
OV
AL
(L
OS
SER
VIC
IOS
CO
MIE
NZA
N A
PA
RTI
R D
E L
A A
PRO
BA
CIÓ
N F
INA
L D
EL
LEA
(Sig
natu
re o
f all
parti
es re
quire
d)(L
as fi
rmas
de
todo
s los
par
ticip
ante
s son
requ
erid
as)
(DIS
TRIT
O)
(Fir
ma
del o
ficia
l del
LEA
Si
gnat
ure
of L
EA O
ffic
ial
NO
TIC
E: U
se o
f thi
s for
m fo
r oth
er th
an it
s int
ende
d us
e co
nstit
utes
frau
d. U
se o
f the
Gre
at S
eal o
f the
Sta
te o
f Ariz
ona
with
out w
ritte
n au
thor
izat
ion
from
the
Stat
e of
Ariz
ona
is p
rohi
bite
d. R
emov
al o
f the
Ariz
ona
Gre
at S
eal,
Stat
e of
Ariz
ona,
A
rizon
a D
epar
tmen
t of E
duca
tion
or a
ny o
ther
refe
renc
e to
this
off
icia
l doc
umen
t fro
m th
is d
ocum
ent i
s cau
se fo
r im
med
iate
te
rmin
atio
n of
any
and
all
cont
ract
s / a
gree
men
ts fo
r Sup
plem
enta
l Edu
catio
n Se
rvic
es T
utor
ing.
Cop
ying
of t
his d
ocum
ent,
for
othe
r tha
n its
inte
nded
use
, with
out w
ritte
n pe
rmis
sion
from
the
Ariz
ona
Dep
artm
ent o
f Edu
catio
n Su
pple
men
tal E
duca
tion
Serv
ices
is st
rictly
forb
idde
n.
r(Fi
rma
del P
rove
edor
)Si
gnat
ure
of P
rovi
de
(Fir
ma
del P
adre
/Mad
re/S
ustit
uto
Sign
atur
e of
P /
G /
E S
(Fir
ma
del E
stud
iant
e)Si
gnat
ure
of S
tude
nt (a
s app
ropr
iate
)
AD
E(S
ES)1
1/06
AD
E (S
ES) 1
1/06
ORI
GIN
ALSI
GN
ATU
REO
RIG
INAL
SIG
NAT
URE
DO
CU
MEN
T TO
DIS
TRIC
T / L
EA O
FFIC
E
PrintF
orm
(RE
SPO
NSA
BIL
IDA
DE
S D
EL
PRO
VE
ED
OR
)
(Des
crip
ción
de
Serv
icio
s)
(Med
idas
de
Des
empe
ño p
ara
Obt
ener
Las
Met
as)
th
()
(Be
Spec
ific)
(Sea
Esp
ecífi
co)
Incl
ude
Dat
e an
d Ti
me
(Inc
luya
la fe
cha
y la
hor
a)
(El p
rove
edor
le d
ará
al e
stud
iant
e lo
s sig
uien
tes s
ervi
cios
de
tuto
ría)
:
(Com
unic
ació
n co
n el
pad
re/m
adre
y p
erso
nal d
e LE
A)
gres
s(E
l pro
veed
or in
form
ará
al p
adre
/mad
re/tu
tor/
sust
ituto
edu
cativ
o y
/ES
Iii
lfP
id(I
ii
ld
lPd
)
City
/ St
ate
(Ciu
dad/
Esta
do)
(Pag
o Pa
ra e
l Pro
veed
or)
Phon
eN
umbe
r:(C
onta
ctLo
catio
n)(N
úmer
ode
Telé
fono
Luga
rde
Con
tact
o)
t(E
l LEA
est
á de
acu
erdo
en
paga
rle
al p
rove
edor
la c
antid
ad to
s
Polic
y Fo
r Abs
ence
(Reg
ulac
ione
s
Initi
also
fpar
ent/
guar
dian
/ES
educ
ativ
o)In
itial
s of P
rovi
der
(Ini
cial
es d
el P
rove
edor
)
DO
CU
MEN
TTO
DIS
TRIC
T/L
EAO
FFIC
E(E
S)=
Educ
atio
nalS
urro
gate
and
is
rem
oved
en e
l
Phon
eN
umbe
r:(C
onta
ctLo
catio
n)(N
úmer
ode
Telé
fono
,Lug
arde
Con
tact
o)
Tuto
ring
Dat
e: (E
ND
)(Fe
cha
del f
in d
e la
Tut
oría
)To
tal N
umbe
r of H
OU
RS
(Núm
ero
Tota
l de
HO
RAS)
:
Thdi
tre
yor
(CA
NC
ELA
MIE
NTO
DE
L A
CU
ER
DO
)
)O
RIG
INAL
SIG
NAT
URE
DO
CU
MEN
TTO
DIS
TRIC
T/L
EAO
FFIC
E(E
S) =
Edu
catio
nalS
urro
gate
)O
RIG
INAL
SIG
NAT
URE
DO
CU
MEN
TTO
DIS
TRIC
T/L
EAO
FFIC
E(E
S)Ed
ucat
iona
l
p
de A
sist
enci
a):
TIE
STI
VO
, LE
ivid
ualiz
edón
de
Met
aca
cion
del
e
date
)(O
bjet
iv
tatio
n.
IV: P
AR
EN
T /
GU
AR
DIA
N /
ES,
LE
A, &
PR
OV
IDE
R S
HA
RE
D R
ESP
ON
SIB
ILI
(RE
SPO
NSI
LID
AD
ES
CO
MPA
RTI
DA
S D
E P
AD
RE
/MA
DR
E/S
UST
ITU
TO E
DU
CA
V: P
RO
VID
ER
RE
SPO
NSI
BIL
ITIE
S
A, Y
PR
OV
EE
DO
R):
A. P
ERFO
RM
AN
CE
MEA
SUR
ES F
OR
MEE
TIN
G G
OA
LS:
Pare
nt a
gree
s to
rele
ase
indi
vidu
al st
uden
t ass
essm
ent d
ata
for e
valu
atio
n of
the
stud
ent's
aca
dem
ic a
chie
vem
ent i
n or
der f
or t
the
Prov
ider
, and
par
ent /
gua
rdia
n / e
duca
tiona
l sur
roga
te to
set t
he a
chie
vem
ent g
oals
for t
he st
uden
t en
treg
ar lo
s dat
os in
divi
dual
es d
e ev
alua
ción
del
est
udia
nte
para
la e
valu
ació
n de
l log
ro a
cadé
mic
o de
l est
udia
nte
para
que
pue
el L
EA, e
l pro
veed
or, y
pad
re/m
adre
/tuto
r/su
stitu
to e
duca
tivo
fijen
las m
etas
de
logr
o pa
ra e
l est
udia
nte)
.
he L
EA,
(Los
pad
res a
cuer
dan
de
Pr
ovid
er w
ill m
easu
re th
e st
uden
t's p
rogr
ess i
n m
eetin
g th
e go
als s
tate
d he
rein
as f
ollo
ws:
P / G
/ ES
Initi
als
(Ini
cial
es d
e P/
M/S
E)da
(E
l Pro
veed
or m
edir
á el
pro
gres
o de
l est
udia
nte
en a
lcan
zar l
as m
etas
indi
cada
s y e
stip
ulad
as c
omo
sigu
e:)
List
Pre
/ Po
st T
est a
nd S
core
s or o
ther
mea
sure
s use
d to
det
erm
ine
acad
emic
pro
gres
s. In
clud
e ho
w p
erfo
rman
ce m
easu
res
fit w
ist
uden
t's IE
P.(L
ista
de
los e
xám
enes
y C
alifi
caci
ones
de
Pre/
Post
u o
tras
med
idas
usa
das p
ara
dete
rmin
ar e
l pro
gres
o ac
adém
ico.
In
cluy
a co
mo
las m
edid
as d
e ej
ecuc
ión
cabe
n co
n el
IEP
(Pla
n de
Edu
caci
ón In
divi
dual
) del
est
udia
nte.
)Pr
ovid
er a
gree
s to
NO
T di
sclo
se th
e na
me
of th
e st
uden
t bei
ng tu
tore
d(E
l pro
veed
or a
cuer
da N
O re
vela
r el n
ombr
e de
l est
udia
nte
que
está
reci
bien
do tu
tori
a).
Prov
ider
Initi
als
(Ini
cial
es d
el P
rove
edor
)
(El p
rove
edor
no
A.
IND
IVID
UA
L ST
UD
ENT
GO
ALS
(MET
AS
IND
IVID
UA
LES
DEL
EST
UD
IAN
TE)-
The
pro
vide
r sha
ll m
ake
no c
hang
es in
an
y st
uden
t's g
oals
with
out t
he w
ritte
n co
nsen
t of t
he L
EA a
nd th
e ch
ild's
pare
nt /
guar
dian
/ ed
ucat
iona
l sur
roga
te
cam
biar
á la
s met
as d
e ni
ngún
est
udia
nte
sin
el c
onse
ntim
ient
o es
crito
del
LEA
y d
e lo
s pad
res/
tuto
r/su
stitu
to e
duca
tivo
del
estu
dian
te).
B. D
ESC
RIP
TIO
N O
F SE
RV
ICES
Des
crip
tion
of G
oals
: (If
a st
uden
t is d
isab
led,
stat
e ho
w th
e go
als f
it th
e st
uden
t's in
unde
r Sec
tion
6 1
5(d)
of t
he In
divi
dual
s with
Dis
abili
ties E
duca
tion
Act
.) (D
escr
ipdi
scap
acita
do, i
ndiq
ue c
omo
las m
etas
enc
ajan
con
el p
rogr
ama
indi
vidu
al d
e la
ed
(d)d
elAc
tode
Educ
ació
nde
Indi
vidu
osco
nD
isca
paci
dade
s)
d ci u
edu
catio
n pr
ogra
m (I
EP)
Prov
ider
will
giv
e th
e st
uden
t the
follo
win
g tu
torin
g se
rvic
ess: s S
i un
estu
dian
te e
s LO
CA
TIO
N (L
UG
AR):
tudi
ante
baj
o Se
cció
n 6
15
Gen
eral
Des
crip
tion
of T
utor
ing
(Des
crip
ción
Gen
eral
de
Tuto
ría)
:In
term
edia
te G
oal
(Met
a In
term
edia
):
C.
CO
MM
UN
ICA
TIO
N W
ITH
PA
REN
TS A
ND
LEA
The
prov
ider
will
info
rm p
aren
t/gua
rdia
n/ed
ucat
iona
l sur
roga
te a
nd L
EA st
aff w
ith a
writ
ten
repo
rt de
scrib
ing
the
stud
ent's
pro
incl
udin
g be
nchm
ark
data
on
a (d
aily
, wee
kly
or m
onth
ly b
asis
)pe
rson
al d
el L
EA c
on u
n re
port
e es
crito
que
des
crib
e el
pro
gres
o de
l est
udia
nte
incl
uyen
do d
atos
de
"ben
chm
ark"
sobr
e un
a (b
ase
diar
ia, s
eman
al o
men
sual
).
Fina
l Goa
l(O
bjet
ivo
Fina
l):
Initi
also
fpar
ent/
guar
dian
(I
nici
ales
delp
adre
/mad
re/s
ustit
uto
B.
TIM
ELIN
E FO
R IM
PRO
VIN
G A
CH
IEV
EMEN
T (F
ECH
A L
IMIT
E PA
RA
MEJ
OR
AR
EL
LOG
RO
) - A
ll st
akeh
olde
rs h
ave
set t
he fo
llow
ing
timel
ines
for i
mpr
ovin
g th
e st
uden
t's a
cade
mic
ach
ieve
men
t. Fo
r stu
dent
s with
dis
abili
ties,
stat
e ho
w th
e tim
fits w
ith th
e st
akeh
olde
rs IE
P (T
odos
los p
artid
ario
s han
fija
do la
s sig
uien
tes f
echa
s lím
ites
para
el m
ejor
amie
nto
del r
endi
mie
nto
acad
émic
o de
l est
udia
nte.
Par
a lo
s est
udia
ntes
con
dis
capa
cida
des,
indi
que
com
o la
fech
a lím
ite e
ncaj
a co
n el
IEP
de lo
s pa
rtid
ario
s):
elin
eV
I: P
AY
ME
NT
(PA
GO
)
PAY
MEN
T TO
TH
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E (D
epar
tam
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zona
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ovid
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la li
sta
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est
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pro
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ilize
pro
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ther
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ntra
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iliza
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) el p
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deb
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esen
tar
copi
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spon
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terc
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y p
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a de
segu
ro a
la U
nida
d de
Adm
inis
trac
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de C
ontr
atos
del
D
epar
tam
ento
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Educ
ació
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Ari
zona
tal c
omo
lo e
s ind
icad
o en
el c
ontr
ato.
AD
E(S
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URE
30
Tolleson Union High School District
Appendix B: Additional Guidance
31
Revised November 2007. Governing Board approved 12/11/07. - 1 -
USE OF FACILITIES
PROCEDURES, POLICIES,
And
RENTAL AGREEMENT
Tolleson High School
Westview High School
LaJoya Community High School
Copper Canyon High School
Sierra Linda High School
Continuing Education Academy (CEA)
District Office Complex
Revised November 2007 Board approved 12/11/07
Revised November 2007. Governing Board approved 12/11/07. - 2 -
TOLLESON UNION HIGH SCHOOL DISTRICT
FACILITIES USE POLICY
FOREWORD
It is the policy of the Tolleson Union High School District #214 that the district’s facilities are part of the school
community and available for use by the community at-large whenever such use does not conflict with regular
school use and activities. The Tolleson Union High School District #214 believes that a fair and equitable fee
schedule should be established that ensures that members of the general school community shall have
appropriate access and opportunity to utilize the facilities of the District.
The fee schedule and facilities use policy shall strive to ensure that the Tolleson Union High School District
#214 does not incur any costs or expense for the community’s use or rental of the District’s facilities and/or
property. Further, the District reserves the right to restrict the use of any facility when it is deemed that
such a restriction is in the best interest of the students, staff, and residents of the Tolleson Union High
School District #214.
When districts decide to make school facilities available to the public, a process for compliance with state
statute needs to be in place. Two important parts of this process, which together constitute a facility use
program, include a risk assessment evaluation and an application procedure.
The risk assessment evaluation should include:
▲ a walk-through of the facility so that the district and applicant can evaluate potential risk to event
attendees or to the district as a result of the event; and
▲ a pre-use guideline summary designed to communicate the steps that must be taken prior to facility
use. These guidelines should alert applicants to their responsibility to maintain a safe environment
for the event and protect the district facility.
Should the occupant not have the necessary general liability coverage to comply with A.R.S. §15-1105 et seq.,
coverage may be purchased through the Arizona School Risk Retention Trust, Inc. (Trust).
The Trust has made arrangements through St. Paul Fire & Marine Insurance Company to make general liability
coverage available to temporary occupants of district facilities. This coverage contains exclusions, most
notably for assault and battery and occupant liability. The policy has a $500 deductible for bodily
injury/property damage on a per claim basis, which the occupant is responsible for in the event of a claim. The
occupant must follow the facility use procedures established by the district. Furthermore, all fees must be paid
in advance of facility use.
The terms and conditions of the district’s policy, not this document, will apply to any and all facility use
contracts.
All rental documents and fee payments are to be returned to the local renting school for processing. The
Assistant Principal for Operations/Athletic Director handles this function.
Revised November 2007. Governing Board approved 12/11/07. - 3 -
DISTRICT - Tolleson Union High School District #214
FACILITY USE PROCEDURE
and
OCCUPANT CHECKLIST
To be completed and signed by the occupant. Check each box.
Y N
1. Read, complete, and sign the Rental Agreement. Will you comply with its terms and
conditions?
2. Do you understand that you are responsible for informing all event participants of the need to
comply with the terms of the Rental Agreement?
3. Do you have the necessary evidence of liability coverage?
If you answered “yes” to questions 1-3, please sign below and return this form to the district along with the
signed Rental Agreement.
If you answered “yes” to questions 1&2 and “no” to question 3, you have the option of purchasing the necessary
general liability coverage through St. Paul Fire & Marine Insurance Company. If you wish to purchase the
insurance, please contact The District Accountant at the District Office. Phone # 623.478.4161. Please allow 5-
7 working days for processing of the certificate.
Upon completion of the rental agreement and facility use guidelines, please sign below and return this form to
the respective school site, along with a signed copy of the Rental Agreement, and a copy of your liability
coverage as outlined in the rental agreement.
Name of occupant’s organization: ____________________________________________________
Signature of occupant:
Name of occupant (print):
Date:________________
Revised November 2007. Governing Board approved 12/11/07. - 4 -
The TUHSD Facilities Use Policy establishes the following facility use categories:
School Associated Groups
Tolleson Union High School District Employee Organizations
Students Activities: Concerts
Association formed for the betterment or improvement of local schools. The School Principal or designee will
be the responsible person to decide which associations meet this requirement.
Institutions of higher learning for in-service classes for school district personnel requested by the Governing
Board, the Superintendent, or his/her designee.
Organized groups within the school community who serve all high school pupils within the school community
and do not charge for admission.
All other school-related activities deemed comparable to above by the Principal or his/her designee.
Community Activities and Non-Profit Civic, Service or Church Organizations.
Service or non-profit community groups or organizations in the general geographical area of a high school who
request permission to use school facilities for an activity involving elementary and/or secondary school age
youth in the community. This classification shall not apply to any activity where proceeds are collected.
Institutions of higher learning other than the “School Associated Groups” listed above.
The classification of other groups or organizations as “Community Activities” will be the responsibility of the
School Principal or his/her designee.
All groups of a non-profit cultural, civic educational or charitable nature except those groups or organizations,
which are school affiliated.
Commercial or Profit-Making Ventures where proceeds are received.
An Organization or group using the facility in an attempt to realize a profit from its activity and where an
admission charge is made or other proceeds are received.
Proposed Fees
School
Associated
Groups
Community Activities / Non-
Profit Entities
Commercial or Profit-
Making Ventures
Revised November 2007. Governing Board approved 12/11/07. - 5 -
No Fees
Charged Hourly charge Hourly charge
Application Fee $10.00
Auditorium - Tolleson $35.00 $70.00
Auditorium -
Westview/Copper
Canyon $50.00 $100.00
Café. Personnel - café
use. $30.00 $60.00
Cafenasium and
Kitchen $35.00 $70.00
Classroom - Standard $20.00 $20.00
Custodial Cleaning
Deposit $100.00
District personnel $35.00 $35.00
Football stadium $40.00 $100.00
Football stadium with
lights $50.00 $120.00
Gymnasium $50.00 $100.00
Gymnasium and locker
room $60.00 $120.00
Kitchen only $25.00 $50.00
Library/Media Center $30.00 $60.00
Parking lot usage $10.00
Playfield – no lights $20.00 $40.00
Playfield with lights $25.00 $50.00
Pool – hourly charge $50.00 $50.00
Room Set-up and Tear
Down $50.00
Sound/Lighting tech. $20.00 $20.00
Specialized Rooms -
computer labs, etc $50.00 $100.00
Security/police
coverage
( applicable rate per entity
charge )
Certified Lifeguard for
Tolleson High Pool
( applicable rate per entity
charge )
2 hour minimum
charge is required for
facility rentals.
RENTAL AGREEMENT
Today’s Date ________ FOR USE OF FACILITIES LOCATED AT: __________________________________ Tolleson Union High School District, Maricopa County, lessor, hereby agrees to lease: Specific Facility to be used: Lessor Contact Person: Phone:
Revised November 2007. Governing Board approved 12/11/07. - 6 -
TO: Name of Lessee or Organization: Lessee Contact Person: Phone: Mailing Address of Lessee or Organization: The following terms and conditions apply to the use and rental of all facilities: (please read before signing)
1. The premises are to be used only for the expressed purposes as identified in the application. 2. No smoking or alcoholic beverages are to be allowed. 3. District staff is to have access to all facilities at all times. 4. All properties and equipment are to be accounted for and left in the same condition as they were at the time of use. 5. No lighting, wiring, or scenery is to be changed except by special permission from the building administrator. 6. Any program of speakers, plays, or presentations must be submitted for approval at the time the rental application is received. 7. Any advertising for the promotion of the program must indicate the sponsoring agent. 8. This District reserves the right to refund deposits paid in advance for rental of any facilities should the building principal or
superintendent decide the usage is not in the best interests of the District. 9. Liability insurance shall be provided by the renter and evidence of same (satisfactory to the District) shall be filed at the time of
application. This insurance shall be provided in the minimum limits of $1,000,000 combined single limit for bodily injuries and property damage. The applicant agrees to name the District as an “additional insured” on the applicant’s liability policy as respects the use of District property.
10. Applicant agrees to comply with all federal, state, and municipal laws, rules, ordinances, regulations, and orders with respect to the use and occupancy thereof. Applicant, during the term of this permit, covenants and agrees to indemnify and hold harmless the District from each and every loss, cost, damage and expense arising out of any accident or other occurrence causing injury to or death of persons or damage to property due to the conditions of the rented premises or the use or neglect thereof by the renter.
11. Renter agrees that it will pay for any unusual wear, tear, breakage, and damage to facility occurring from the use of the facility or equipment. Should a facility or equipment be damaged the renter agrees to reimburse the District for the full cost of repair or replacement. The renter agrees to provide any necessary security and/or maintenance personnel as required by the District.
Purpose: Date(s): Time: a.m. p.m. To: a.m. p.m. Special equipment needed:
RENT IS PAYABLE IN ADVANCE. It is understood that all rates quoted, as well as other conditions stipulated, are a part of this agreement. BASE CHARGE OF FACILITY TO BE USED…………………………… ……………….$ ____________ ADDITIONAL CHARGES: TUHSD Staff (paid directly to individual) $____________
Utility Costs…………………………………..$ ____________
Other ……………………………………… $ ___________
Make check payable to ________________________________________________ TOTAL $____________ This agreement is accepted upon the foregoing terms and conditions: Please sign and return all copies to the Assistant Principal for Athletics. NOTE: THIS AGREEMENT IS NOT VALID AND FACILITIES WILL NOT BE MADE AVAILABLE UNTIL SIGNED BY THE PRINCIPAL OR ASSISTANT PRINCIPAL IN CHARGE OF FACILITIES AND A CERTIFICATE OF INSURANCE IS FILED WITH SAME.
For Lessor: Tolleson Union High School District No. 214 For Lessee : ________________________________________ Name of Lessee or Organization
By: __________________________________________ By: _______________________________________________ Principal or Assistant Principal Signature & Title
Insurance Certificate Received ____________________ Fee Waiver Approval _________________________________ Expiration Date Superintendent or Designee
IN-KIND COMPENSATION IN LIEU OF FEE PAYMENT
Name of Lessee or Organization:__________________________ agrees to the following IN-KIND compensation in lieu of the required fees as set forth in the fee schedule. Required Fee based on the assigned category:______________________
Revised November 2007. Governing Board approved 12/11/07. - 7 -
Summary of the IN-KIND compensation:____________________________________________________________________________
____________________________ ___________________________ Name of Lessee or Organization Superintendent or Designee ___________________________ Date
38
Tolleson Union High School District
Appendix C: Program Monitoring and Reporting
39
AZ Department of Education (ADE)
Supplemental Education Services (SES) Program
Incident Report Template
Overall Guidelines
This Report is designed for use by School Staff, Parents, Vendors and ADE to document any
incident pertaining to activities or practices surrounding the SES program.
Copies of reports are to be kept on file at the District.
Only Reports of an unresolved incident or serious transgression* should be forwarded to both
the Procurement Officer at ADE ([email protected]) and the ADE SES Choice Coordinator
([email protected]). ADE reserves the right to implement a Plan of Improvement for
Providers named in an Incident Report. In addition, Incident Reports will be taken into
consideration as the Arizona SES Provider Proposal Committee reviews Provider Proposals for
the next school year (2011-2012).
*An incident is defined as an event with potentially serious consequences.
*A serious transgression includes, but is not limited to, any act that endangers a child.
Specific Instructions:
1. All asterisked (*) information on this Report must be included when the report is
submitted. Failure to do so may result in a delay.
2. Include dates of contact, names of contacts and results of discussions.
3. The District SES Coordinator will review the Report and if necessary, contact the
appropriate parties to identify a mutually convenient time to discuss the issues.
4. After the review has been completed by the District SES Coordinator, the appropriate
parties will be contacted and provided with written results.
Arizona Department of Education (ADE) Supplemental Education Services (SES) Program
Incident Report
School Representative Information
School Name
Contact Name
Office Phone #
Mobile #
Vendor Information
Vendor
Contact Name
Office Phone#
Mobile#
Parent/Student Information
Student Name
Parent Name
Phone #
Mobile #
Address
A copy of this incident will be provided to the appropriate parties.
Please indicate below where copies of the report were sent.
Report Delivery
Mailed To: Date:
Hand Delivered To: Date:
Emailed/Faxed To: Date:
Describe the nature of the issue(s) and any facts relating to the incident:
Describe any recommendations (if any) you have to resolve this issue:
Describe what actions the school has taken to address this issue:
Signature
Print Name:
(This template was adapted from the Creighton Incident Report)
Completed by: Today’s Date: / /
Signature of Submitting Party: Date: / /
SES COORDINATOR REPORT 2012 SES Coordinator: Joan Curtis
Email this form to: [email protected]
PART 1 DISTRICT REPORT
District/ LEA
District Address
Contact
Telephone
Email Address
Provider
Provider Contact
Date Submitted
Describe in narrative form performance issues. Be accurate, complete and factual.
Keep in mind the following questions:
1) Compliance with Agreement process 5) Compliance with state and district rules for providing services 2) Communication with provider 6) Submission of bills 3) Reporting to parents, teachers, district 7) Other 4) Quality of instructional staff
This document should be used to report positive or negative performance
of an Arizona SES Approved Provider and to indicate whether corrective
action is required. Please complete one report for each Provider.
