4150.PA2 - Out of District Application ## 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.