TEENAGE PREGNANT & PARENTING STUDENTS
(TAPPS) PROGRAM
Irving Independent School District
2008-09
APPLICATION
TAPPS REFERRAL FORM:
Name: ______
Last First Middle
If married, maiden name: ______
Spouse’s name: ______
Address: ______
Street Address Apt. # City Zip Code
Name of Apartment Complex: ______
Home Phone: ___(_____)______Cell Phone: ___(_____)______
Employer: ______Work Phone: ___(_____)______
Daytime Phone: ___(_____)______Hours/days worked per week: ______
If no phone, how can you be reached? ______
With whom do you live: Parent ( ) Guardian ( ) Spouse ( ) Other ( )
If Other, please explain: ______
Name of student’s parent(s) or guardian(s): ______
Address: ______
Street Address Apt # City Zip Code
Home Phone:___(_____)______Work Phone: ___(_____)______
Home Campus: ______Grade: ______Date of Birth: ______
School ID#: ______Social Security #: ______
Email Address: ______
Name of other parent: ______
Is the other parent still in school? Yes ( ) No ( )
If yes, what school does s/he attend? ______
School City
TAPPS STUDENT COMMITMENT & PARENTAL CONSENT
Irving Independent School District is committed to helping pregnant and parenting teens in the community complete their education and graduate from school. The Teenage Pregnant & Parenting Students (TAPPS) Program is designed to help students meet their educational goals. Pregnant students have the option of attending school classes at their current campus or transferring to Union Bower Center for Learning (UBCL). Regardless of which campus you attend, the following guidelines will help you succeed in the program:
1. Students will work toward the goal of receiving a high school diploma.
2. Students will report to school on time and maintain regular school attendance.
3. Students will keep communication with the TAPPS staff and inform any changes in address, phone number(s), or marital status.
4. If using the TAPPS bus service, the student will follow all bus rules, informing the bus driver when absent and not riding the bus.
5. Students will bring a doctor, WIC, Medicaid note when absent for pregnancy related issues. The notes must have an official stamp or be on letterhead of the professional agency. A note from the parent/guardian/spouse is required for all absences. The notes for absences must be received the first day back after the absence.
6. Upon delivery of the baby:
a. The student or parent is required to call the TAPPS PRS Coordinator at their campus on the day of the delivery or the first weekday if delivery occurs on a weekend, to advise that the child has been born.
b. The student will receive six weeks (30 days) of instruction by the TAPPS maternity leave instructor at a facility off campus. The instruction will be provided twice weekly for two hours each time. The student will be marked present for the entire week if a total of 4 hours of instruction is provided. If a holiday occurs during the six weeks period, the day or days of the holiday will be counted toward the total of 30 weekdays for maternity leave.
c. Contact by the maternity leave instructor will be made the day the students notifies the TAPPS office of delivery and an instruction schedule will be set, beginning the week of delivery.
7. Students will obtain a doctor’s release before returning to regular school schedule after delivery. The doctor’s release should be in writing and presented to attendance upon returning to school full time.
The TAPPS Program is ready to help you set and reach your goals. Your cooperation is necessary to make the program work for you.
______
Student’s Signature Date
______
Parent/Guardian Signature Date
The TAPPS Program has a licensed social worker to assist students with obtaining valuable community resources and to offer supportive counseling as needed for social or emotional issues. Services provided are confidential to the extent allowable by law. Parental consent for social work services for students under age 18 is requested.
_____ I give consent for my child to receive school social work services for this academic year, through the Irving ISD TAPPS Program. I understand that if I have any questions I can contact Angela Lutts, LMSW, at the Administrative Annex Building, (972) 273-6038.
_____ I do NOT give consent for my child to receive school social work services for this academic year.
______
Parent/Guardian Signature Date
PRENATAL PHYSICIAN FORM
State law requires the regular school attendance of this student. Please complete the following information so that an alternate education plan, if necessary, may be considered. Please direct inquiries to the TAPPS Coordinator
THIS FORM TO BE COMPLETED BY PHYSICIAN/NURSE-MIDWIFE
Patient’s Name: ______Phone: ___(_____)______
Address: ______
City: ______State: ______Zip Code: ______
Date of Birth: ______
Are there complications with this pregnancy? Yes ( ) No ( )
If yes, please explain: ______
Date pregnancy diagnosed: ______Expected Delivery Date: ______
Is there any reason why this student cannot attend school regularly? Yes ( ) No ( )
If yes, please explain: ______
Is there any reason why this student could not ride a school bus? Yes ( ) No ( )
If yes, please explain: ______
What specific arrangements would permit regular class attendance? ______
______
Physician/Mid-Wife Signature Date
Name of Clinic/Office: ______
Clinic/Office Address: ______
Phone: ___(_____)______Fax: ___(_____)______
I give my permission for the above information to be released to Union Bower Center for Learning:
______
Signature of Student Date
______
Signature of Parent/Guardian Date
AUTHORIZATION FOR RELEASE OF INFORMATION
I authorize release of medical information, as needed, concerning ______
Student’s Name
to the Irving Independent School District Teenage Pregnant & Parenting Students (TAPPS) Program.
Name of physician/medical agency for prenatal care:______
Address: ______
Street/Suite No./PO No. City, State Zip Code
Phone: ___(_____)______Fax: ___(_____)______
______
Signature of Student Date
______
Signature of Parent/Guardian/Spouse Date
INTAKE AND NEEDS ASSESSMENT FORM
TAPPS PROGRAM
The information requested will enable the PRS Coordinator to assist you in accessing support services. Please answer the following questions.
Name: ______ID#: ______
Are you: pregnant? ____ a parenting student? ____ If you are a parenting student, please list the names and birthdates for your child(ren):
______
First and Last Name(s) of child(ren) Child’s date of birth
Does your child (or will your child) attend a daycare provided through the TAPPS program? Yes___ No___
If yes, which daycare does your child (or will your child) attend?______
If no, who takes care of (or will take care of) your child while you are in school?______
What are your goals for the next 5 years? ______
10 years? ______
Future educational plans:______
Check needed services only if you currently need them or will in the near future. Then check how important your need for the service is:
Need: Very Important Somewhat Important Not Very Important
____Complete school ______
____Academic Tutoring ______
____Financial help ______
____A place to live ______
____Food ______
____Clothing for me ______
____Clothing for my child ______
____Job counseling ______
____Personal counseling ______
____Family counseling ______
____Medicaid/Insurance for me ______
____Medicaid for my child ______
____A doctor for myself ______
____A doctor for my child ______
____Parenting Information ______
____Transportation ______
____Daycare for my child ______
____Birth control information ______
____Child Support ______
____WIC ______
Other information you would like us to know in order to help you: ______
______