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: ___________

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: _____