4150.PA3 - Out of County Application ## 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: _____