Bremerton School District 100-C

Bremerton School District 100-C

134 Marion Avenue North, Bremerton, WA 98312

(360) 473-1006

APPLICATION FOR NON-RESIDENT ADMISSION

Section I – Student Information – TO BE COMPLETED BY PARENT

Student Name: / Birth Date: / School Year requested:
Grade for year requested:
Parent/Guardian Name: / Home Phone:
Work Phone:
Street Address:
City : Zip: / Mailing Address (if different)
ResidentSchool District: / Requesting to Attend (school name):
LastSchool Attended:

Mark the appropriate reason (check one box only) for your request for this transfer.

Closer to parent’s place of work or child careEducational conditions likely to improve

Financial/ Safety/ Health ConditionFamily/home conditions

Educational Continuity - new request ___ continuing request___

Program not offered in resident district

Full time Bremerton School District employee assigned to a school: Staff Name: Building:

Other:

Has your child ever been enrolled in special education classes? Yes No Currently? Yes No

I verify that the above information is accurate and current. I understand that this approved Non-resident admission is for the ______ school year only. I understand that the parent/guardian must assume responsibility for adequate transportation to and from school.

Signature of parent/guardian orStudent if age 18 or over: Date: ______

SECTIONII– BREMERTON SCHOOL DISTRICT/ACCEPTING DISTRICT

Principal calls previous school, completes this section, and returns the form to Bremerton School District K-12 School Support.

The BremertonSchool District has determined that:

YesNo

Student attends school regularly.

Space is available in the grade level/classes at the building in which the student desires to be enrolled.

This student does not have a current I.E.P.

Appropriate educational programs or services are available to improve the student’s condition.

The student is not likely to create a risk to the health or safety of other students or staff.

Recommendation of Receiving Principal: Approved Denied Date:

If ‘denied’ a letter of explanation must be attached.

Recommendation of Special Education: Approved Denied Date:

FINAL DISTRICT DECISION: Approved Denied Date:

Approval contingent upon regular attendance, behavior, and availability of appropriate programs or services if student’s needs change.

If the application is denied, the parent or guardian has the right to petition the Board, upon five school business days prior notice, for review of the decision and to have a hearing before the Board at its next regular meeting.

Section III – Releasing District

releasing school district

The School District hereby releases said student and waives attendance claims and state apportionment claims for said student from

to . It shall be the responsibility of the parent to provide transportation to and from school.

Signature of Superintendent/DesigneeDate

Return completed form to: Assistant Superintendent K-12 School Support, 134 Marion Avenue North, Bremerton, WA98312

Distribution: AdministrationParent Releasing School District______Receiving School

Revised 12/2013