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EXHIBIT

OPEN  ENROLLMENT

ATTENDANCE APPLICATION
File this application at your current school office

Student's name  _________________________________________________
                            Last                                   First                                      M.I.

Current grade _______________   Birth date __________________________

Parent/Guardian Information:  Must be listed on Birth Certificate or Legal Custody Documentation

Student Lives with:  ____ Both Parents   ____ Mother Only   ____ Father Only

____ Guardian   ____ Foster   ____ Other, please specify:________________

For joint Legal Decisiion-Making, please indentify Primary Parent/Guardian:

____ Mother   ____ Father

Mother's name  __________________________________________________
                            Last                                   First                                      M.I.

Home address __________________________________________________
                           Street                                 City                                       Zip

Home phone _____________ Message _____________ Cell _____________

E-mail address __________________________________________________

Father's name  __________________________________________________
                            Last                                   First                                      M.I.

Home address __________________________________________________
                           Street                                 City                                       Zip

Home phone _____________ Message _____________ Cell _____________

E-mail address __________________________________________________

The above-named student:   ◻ resides outside the School District; or
                                                 ◻ resides within the School District

Present school of attendance:

School _________________________   City __________________________

Request assignment to  ___________________________________________ 

Is the above-named student:

Participating in or will the student need participation in any special school programs?  (Resource, learning disabled, gifted, et cetera)  ◻  Yes   ◻  No  If yes, please complete the section titled "Special Programs."

Expelled  or long-term suspended from any school or school district?  ◻  Yes   ◻  No

Out of school pending further disciplinary action such as expulsion or long-term suspension from any school or school district?  ◻  Yes   ◻  No

Is in compliance with conditions imposed by a juvenile court?  ◻  Yes   ◻  No   ◻  N/A

Is in compliance with a condition of disciplinary action in any school or school district?  ◻  Yes   ◻  No   ◻  N/A

Other siblings who attend or will be attending school:

Student's
name  _________________________________________________________
           Last                                First                   Current grade               School

Student's
name  _________________________________________________________
           Last                                First                   Current grade               School

Student's
name  _________________________________________________________
           Last                                First                   Current grade               School

Special  Programs

Please identify any special programs your child has participated in or special help received from previous school personnel and any anticipated special school programs or services.

◻  My child has participated in or it is anticipated will need to participate in the program(s) or receive the services listed below:

◻  Gifted/Talented

◻  Special Education/Exceptional Student Services

Please check all that apply:

◻  Adaptive Physical Education     ◻  Occupational Therapy

◻  Speech/Language Therapy       ◻  ESS/SPED (self-contained)

◻  Resource                                   ◻  Vision

◻  Special Education Preschool     ◻  Hearing

◻  Physical Therapy                       ◻  Assistive Technology

◻  Transportation as "related service"

◻  Section 504 (school will need current Accommodation Plan)

◻  English Learner Program (EL)

◻  Other (explain) ___________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

The signatory affirms that the student will abide by the rules, standards, attendance requirements, and policies of the school and District if enrolled.

                                             Proof of Residence must be provided with application.


___________________________________     _________________________
     Signature of Parent or Legal Guardian                              Date

Providing false information on this form may result in the application being denied or admission revoked.

FOR DISTRICT USE ONLY  ***  DO NOT WRITE BELOW THIS LINE
 

Student's full name _______________________________________________

Student number ______________________   Date stamp ________________
                                                                                                     Filing Date

◻  Accepted  

◻  Placed on waiting list     

◻  Rejected - Reason for rejection ___________________________________


Principal _______________________________________   Date ___________