4150.PA1 - Pupil Release ## 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: _____