PA-1 AVERY COUNTY SCHOOLS 775 Cranberry Street, Newland, N.C. 28657 828.733.6006 828.733.8943 (fax)
APPLICATION FOR PUPIL RELEASE
Date: ___
Name of Student: ____________
Date of Student’s Birth: __ Age: _ Present Grade: __
Father’s Name: ________
Address: _____________
Phone: ___ Emergency Phone: _____
Mother’s Name: ________
Address: _____________
Phone: ___ Emergency Phone: _____
With Whom Does the Student Reside?: ______
Name of Person/Entity with Legal Custody (by Court Decree) Other Than Parent:________
Relationship: ____________________________________
Copy of Court Decree Must Be Attached
Address: _____________
Phone: ___ Emergency Phone: ___
School Student Is Currently Attending: ______
SCHOOL TO WHICH ASSIGNMENT IS REQUESTED: _______
COUNTY: ____________
PA-1
APPLICATION FOR PUPIL RELEASE
STUDENT NAME: ____________
List names of any brothers or sisters now attending Avery County Public Schools and the name of school each child attends:
NAME SCHOOL
_____ ____ _____ ____ _____ ____ _____ ____
State specific reason(s) for the request for assignment of the student to a unit outside of Avery County:
(Attach additional sheets if necessary.)
SIGNATURE OF APPLICANT(S)
Mother’s Signature: __________
Father’s Signature: ___________
WITHOUT COPY OF COURT DECREE (WHEN APPLICABLE), THIS APPLICATION WILL BE
DENIED. Person /Entity Having Legal Custody (by Court Decree) Other Than Parent Signature: _______
DO NOT WRITE BELOW THIS LINE
STIPULATIONS OF APPROVAL:
Requests for assignment of out of county students are considered by the Avery County Board of Education on a year to year basis. This approval is valid for the current school year only (__). APPLICATION MUST BE MADE EACH YEAR.
APPROVED BY ACTION OF THE BOARD BY: ___ DATE: _ ASSIGNED SCHOOL: _______
DENIED BY ACTION OF THE BOARD BY: _____ DATE: __
Letter of Approval/Denial Forwarded DATE: _____
c: Assigned District School: _____
County of Reassignment Request: _____