PA-3 AVERY COUNTY SCHOOLS 775 Cranberry Street, Newland, N.C. 28657 828.733.6006 828.733.8943 (fax)

                  APPLICATION FOR PUPIL ASSIGNMENT
                          From Out of County
            Student Must Also Complete Form PA 100 available at the School

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) _____

COPY OF WRITTEN RELEASE FROM BOARD OF EDUCATION OF DOMICILE* * SCHOOL SYSTEM MUST BE ATTACHED.

SCHOOL TO WHICH ASSIGNMENT IS REQUESTED: _____ *DOMICILE, as to parent or legal guardian/custodian usually means the place of residence. PA-3

APPLICATION FOR PUPIL ASSIGNMENT – From Out of 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.)

WITHOUT WRITTEN RELEASE FROM BOARD OF EDUCATION OF PRIOR SCHOOL SYSTEM IN WHICH PARENT OR LEGAL GUARDIAN/CUSTODIAN IS DOMICILED AND COPY OF COURT DECREE (WHEN APPLICABLE), THIS APPLICATION WILL BE DENIED.

                                 SIGNATURE OF APPLICANT(S)

Mother’s Signature: __________

Father’s Signature: ___________

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: _____