Out of District Student Application

STUDENT INFORMATION

Student Name (Last, First, Middle Initial)*

Grade Student Will Enter:

Any additional students to add?

YesNo

Second Student Name (Last, First, Middle Initial)

Second Student Grade Level

Street Address:*

City, Zip Code:*

Home Phone:*

Father / Guardian Name (Last, First):*

Work Phone:*

Cell Phone:

E-mail Address:

Mother / Guardian Name (Last, First):*

Work Phone:*

Cell Phone:

E-Mail Address:

Is this a renewal? (Did your student attend Elder Grove School this past year?)*

YesNo

TRANSFER REQUEST

Please list any schools your child has attended in the last four years. List them in chronological order with the one at the top being the most recent school attended.

School Last Attended:

Years Attended:

School Phone Number:

School:

Years Attended:

School Phone Number:

School:

Years Attended:

School Phone Number:

School:

Years Attended:

School Phone Number:

REASON FOR TRANSFER

In a brief paragraph, please explain specific reasons for wanting to transfer your child to attend Elder Grove School as an Out of District Student.

Reason For Transfer:*

STUDENT HISTORY

ATTENDANCE:

Did your child miss more than 10 days of school during the last school year?*

YesNo

If yes, please explain:

STUDENT BEHAVIOR:

Has your child received In-School Suspension, Out of School Suspension or had a past history of behavioral concerns (detentions, numerous parent meetings, etc.) in the past 4 years?*

YesNo

If yes, please explain:

HOMEWORK:

Has your child, during the last school year, had any problem getting homework in on time?*

YesNo

If yes, please explain:

DISCLAIMER / PARENT SIGNATURE

By typing your name below, you are stating that everything entered on this application is correct to the best of your knowledge. If the school district learns that there was falsification to the application, then the application will be voided and the student will not be able to attend Elder Grove School. The submission of this form also indicates that you have reviewed, understand and will comply with the:

Elder Grove Out of District Student Policy

Your Name (acting signature):*

Date:*

Date

Out-of-District Application