Date of Application:	Today’s Date.
(Form due for consideration on or before April 15th)

Student’s Name:	Click or tap here to enter text.

SCHOOL YOU ARE REQUESTING OPEN ENROLLMENT TO ATTEND:	Choose a school

FOR SCHOOL YEAR: School Year

☐Male	☐Female	Date of Birth: Date of Birth Grade: Choose an item. Student ID: Click or tap here to enter text.

Student lives with (name):	Click or tap here to enter text.	Relationship to student:	Click or tap here to enter text.

Physical Address:	Click or tap here to enter text.
Mailing Address (if different):	Click or tap here to enter text.

Home Phone:	Click or tap here to enter text.	Cell Phone:	Click or tap here to enter text.	Email:	Click or tap here to enter text.

REASON FOR REQUEST (Required):	Reason for request
School student SHOULD BE attending:	School you should be attending
If out of District, please name school:	Click or tap here to enter text.

Non-resident 9-12th grade requests must have the most recent report card attached.

If in grade 9-12, how many credits has student earned? Click or tap here to enter text.

☐ Yes	☐ No	Has the student ever been suspended or expelled from a school?

☐ Yes	☐ No	Is the student currently under suspension or expulsion or in the process of being suspended or expelled from another school?

☐ Yes	☐ No	Is the student currently being supervised by a juvenile court?

Please complete the following information. This will be helpful in planning a program for your child.

My child HAS participated in the following program(s) or receive the services listed below:

☐ Gifted (Please check one)	☐ previously identified

☐ pending testing results

☐ ELL (Please check one)	☐ previously identified

☐ pending testing results

☐ Reading (Please check one)	☐ previously identified

☐ pending testing results

☐ Section 504 student with a disability (needs a current Accommodation Plan)

☐ Special Education (Attach IEP and psycho educational evaluation report if non-resident)

By signing this document, you are affirming your understanding that you are responsible for transporting your child to and from school and guaranteeing his or her attendance on a regular basis.

Parent/Guardian Signature:	Click or tap here to enter text.	Date:	Click or tap to enter a date.

Providing false information on this form will result in the application being denied or admission being revoked. The parent/guardian signing this application affirms that the student seeking enrollment will abide by the rules and regulations that govern students at the school where the student seeks enrollment. Failure to comply with school and district rules could lead to revocation of open enrollment status.

FOR OFFICE USE ONLY

☐	Open Enrollment Request Approved
☐	Open Enrollment Request DENIED
Reason Denied: Click or tap here to enter text.
Signature of Authorizing Administrator:	Click or tap here to enter text.