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: ___________

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: _____