Bloom Child

Verification of Address Form

To be completed by the person certifying that individuals wishing to register student(s) reside in their home. I,, am a legal resident of ISD and County, Texas, residing at: House Number and Street Apt# City/State Zip

I certify that the following persons reside with me at the above given address: Parent/Guardian: First Middle Last

Parent/Guardian: First Middle Last

Child: First Middle Last Age

Child: First Middle Last Age

Child: First Middle Last Age

Child: First Middle Last Age

I am submitting the following as my proof of residence at the above address e.g., recently paid rent receipt, current lease agreement, or other item listed in the Proof of Residency Letter provided by Bloom Academy Charter School: Based on this address, the student(s) (is/are) seeking admission to Bloom Academy Charter School. I understand that if the parent(s) and child(ren) move from this location out of this attendance zone, or if this information is found to be false, the above-named child(ren) may be withdrawn from Bloom Academy Charter School. I attest and affirm that and his/her child(ren) have resided with me since, and will continue to reside with me for the duration of the school year . To be completed in the presence of a notary

Printed Name of Resident: Printed Name of Parent/Guardian: Signature: Signature:

Date of signature: Date of signature:

SWORN TO AND SUBSRCRIBED BEFORE ME this the day of 20 . My commission expires: Signature of Notary Public (Notary Seal)