4008 - Student to Attend School Out of Bounds

Date: _________________
Time: _________________
Fee: _________________
Initial:_________________

Application for Student to Attend School
Out of School or District Boundaries
(As required by 53A-2-207(3)(a), U.C.A. 1953)

1 Student:	Grade
2. Social Security # or Student ID. #:
3. Male: Female:
4. Parent or legal guardian:
5. Parent's or legal guardian's address:
6. Student's legal residence:
7. Father: ( )	Work Phone
8. Mother: ( )	Work Phone
9. Student's home phone number: ( )
10. District in which student currently resides:
11. Has the student ever been suspended or expelled from a school? Yes No
If yes, please explain:
12. School, grade level and/or program currently attending:
13. District, school and specific program (if any) requested:
14. Has the student ever attended in the school district requested? Yes No
If yes, where When
15. Special Programs/Services
(a) What specific special services has the student received previously?
(b) What special services is the student currently receiving?
(c) Are there other programs or activities that the student is participating in?

(parent or legal guardian)

THIS FORM MUST BE COMPLETED AND SUBMITTED TO:

(district office or requested school, as designated by district of request)

ANY FALSIFICATION OF THE ABOVE INFORMATION WILL RESULT IN CANCELLATION OF A TRANSFER PERMIT
Application: Accepted ___________ Rejected ___________
If rejected, reason for rejection:

_________________________________________________________________________________________________

_____________________________________________________________________________________________

Signature: _______________________________________________________________________
(superintendent or superintendent's designee of receiving district)