About the student

First Name *

Last Name *

Student Age *

Program serves ages 7–17.

Campus Name *

Reason for referral *

Chronic absence (missing about 10% or more of days)

10+ unexcused absences in six months

Truancy court involvement

Behavioral or disciplinary concern

Concern about the student’s engagement

Other

Brief Note

Please do not include sensitive medical or disciplinary detail here.

Parent Consent

Consent to Release of Information (FERPA)

1. I authorize my child's school, school district, the Texas Education Agency, and the City of Houston Health Department to release to MCG — and I authorize MCG to receive and, as needed, share back with those entities — information about my child needed to plan, deliver, evaluate, and report on program services. This may include: enrollment and demographic information, attendance records, grades and report cards, test scores, class schedules, disciplinary records, behavioral information, special education information, and a record of interventions and services provided.

2. I understand this information will be used to plan and adjust services, to track participation, and to evaluate the program, and will be kept confidential to the extent permitted by law.

3. I understand this authorization is subject to the Family Educational Rights and Privacy Act (FERPA) and applicable state law; that I may inspect the records released; and that I may revoke this authorization in writing at any time, except where action has already been taken in reliance on it.

4. This authorization remains in effect for the program/contract period and for the record-retention period required by the program's funding, unless I revoke it sooner.

Parent Full Name *

Parent FERPA Consent Signature *

Clear

By signing you are agreeing to the release of your student's information as described above.

Communication Preferences

I give permission for MCG to contact me (and my middle- or high-school child where appropriate) by the methods I check below. I understand I may opt out at any time and that staff will reach out during business hours.

Text messaging consent. By checking “Text message,” I consent to receive non-marketing text messages from The Murchison Consulting Group about my child’s participation in the program. Message frequency varies; message and data rates may apply. Reply HELP for help, STOP to opt out.

Parent Communication Preferences

Phone Call

Text Messaging

Video Conferencing

Parent Phone Number *

Parent Email *

Language Spoken in the Home

English

Spanish

Vietnamese

Other

Terms & Conditions

By checking this box, I consent to receive non-marketing text messages from The Murchison Consulting Group about Truancy Project. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from The Murchison Consulting Group at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.