PA-2 AVERY COUNTY SCHOOLS 775 Cranberry Street, Newland, N.C. 28657 828.733.6006 828.733.8943 (fax)

                  APPLICATION FOR PUPIL ASSIGNMENT
                     Out of District – Within County

This application must be submitted and considered annually based on the following priorities: 1) space availability, 2) service availability, and 3) prior attendance, tardies, behavior, and academic performance.

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: _____

Name of Person/Entity with Legal Custody (by Court Decree) Other Than Parent:________ Copy of Court Decree Must Be Attached

Address: _____________

Phone: ___ Emergency Phone: ___

With Whom Does the Student Reside?: ______

                       Relationship: ____________________________________

Last School Student Attended: (School) ______

                           (City/State) ____________________________________

SCHOOL TO WHICH CHILD HAS BEEN ASSIGNED: ________

SCHOOL TO WHICH REASSIGNMENT IS REQUESTED: _____

                                            COUNTY: _______________________

PA-2 APPLICATION FOR PUPIL ASSIGNMENT – Out of District – Within County

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 school outside the district in which the student is domicile:

                     (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

 APPROVED _______ DATE: ____ STIPULATION OF APPROVAL:

Parents are required to provide transportation for students attending school out of assigned district.

This approval is contingent upon class size and available space in the school in which request for reassignment is being made.

 DENIED ________ DATE: _____