UNIFIED SCHOOL DISTRICT NO. 309 NICKERSON - SOUTH HUTCHINSON

FORM D.04 12/18/15

OUT-OF-DISTRICT ADMISSION REQUEST (Use a separate request form for each student.)

SCHOOL YEAR ________________

NAME OF STUDENT: ___________________________________________________________________________________ PARENT/GUARDIAN: ______________________________________________________ DATE: ______________________ ADDRESS: ______________________________________________________ TELEPHONE #: ________________________ CITY: ___________________________________________________________________ ZIP CODE: ____________________ DESCRIBE LOCATION IF RURAL ROUTE: _________________________________________________________________ _______________________________________________________________________________________________________ U.S.D. 309 SCHOOL YOU WISH STUDENT TO ATTEND: _____________________________________________________ SCHOOL DISTRICT NOW RESIDING IN: ___________________________________________________________________ LAST SCHOOL ATTENDED: ______________________________________________________________________________ ATTENDANCE RECORD AT LAST SCHOOL (Days absent last year): ____________________________________________ GRADE LEVEL (Last school): _____________________________________ IN GOOD STANDING? ___________________ REASON FOR NOT ATTENDING HOME SCHOOL DISTRICT: _________________________________________________ _______________________________________________________________________________________________________ DOES STUDENT HAVE AN INDIVIDUAL EDUCATION PLAN (IEP)? ___________________________________________ THE BOARD OF EDUCATION RESERVES THE RIGHT TO CHARGE TUITION The information on the back side of this form must be completed if bus transportation is desired. Parent’s Signature: ____________________________________________ PLEASE NOTE: IT IS NECESSARY THAT YOU RETURN THIS FORM TO THE PRINCIPAL OF THE SCHOOL YOU WISH YOUR CHILD TO ATTEND IN THIS DISTRICT. ******************************************************************************************************* Attendance record and standing at last school was verified: Yes: __________________ No: __________________ Principal’s Remarks: ______________________________________________________________________________________ _______________________________________________________________________________________________________ Recommended: __________ Not Recommended: __________ Principal: ____________________________________________ Approved: ______________ Not Approved: ______________ Superintendent: _______________________________________ Superintendent’s Remarks: _________________________________________________________________________________ _______________________________________________________________________________________________________ ___________________________________________________________________ Date: _______________________________ (Original to Superintendent, copy return to Principal, Transportation Department, and copy mailed to parent). (Over)

REQUEST FOR OUT-OF-DISTRICT STUDENT TRANSPORTATION CONDITIONS FOR TRANSPORTATION OF OUT-OF-DISTRICT STUDENTS: 1.

Transportation is provided only on the basis of “available space” on the bus.

2.

Students must board the bus in the district and U.S.D. 309 school buses will not pick up or deliver students to any point outside of the district.

3.

School buses will not alter their normal routes to pick up out-of-district students.

NO CHARGE FOR OUT-OF-DISTRICT STUDENT TRANSPORTATION PROVIDED THE STUDENT MEETS THE BUS IN THE BOUNDARIES OF U.S.D. 309. LOCATION WHERE STUDENT DESIRES TO BOARD BUS: ____________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ******************************************************************************************************** Transportation Supervisor’s Remarks: _________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Recommended: _____________________________________

Not Recommended: ___________________________________

Date Service to Start if Approved: ____________________________________________________________________________ Boarding Location: ________________________________________________________________________________________

USD 309 does not discriminate on the basis of sex, race, color, national origin, handicap or age in admission or access to, or treatment, or employment in its programs or activities. Any questions regarding USD 309’s compliance with Title VI, Title IX, or Section 504 including information about the existance and location of services, activities, and facilities that are accessible to and useable by disabled persons may be directed to the Business Manager, who can be reached at (620)663-7141, 4501 W. 4th Ave., Hutchinson, KS  67501, or to the Superintendent of USD 309.