Geographic Exception Request Form Chp 13-1
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1
2GEOGRAPHIC EXCEPTION REQUEST
STATE OF HAWAII
DEPARTMENT OF EDUCATION
FORM CHP 13-1
P.O. BOX 2360
(Revised December 2014)
HONOLULU, HAWAII 96804
THE GEOGRAPHIC EXCEPTION FORM DOES NOT APPLY TO HOMELESS STUDENTS UNLESS
the request is for a student to attend a school other than the school of origin or home school .
SECTION I – To be completed by parent/legal guardian of student and submitted to the Home School if the
student is new to the D.O.E. or to the current school where the student is currently enrolled. Submit to the
Principal with a self-addressed, stamped envelope attached to each Geographic Exception Request Form.
Requesting Geographic Exception to Attend:
For School Year
-
Name of School
For Grade Level
M
1. Student’s Legal Name
Last
First
Middle Initial
2. Birth Date
/
/
Gender
Male
Female
q
q
mm
/
dd
/
yy
3. Current School
Current Grade Level
4. Residential Address
FOR SCHOOL USE ONLY
Student ID# (10 Digits)
City
State
Zip Code
5. Requester’s Name
Home School Code
Address
Current School Code
City
State
Zip Code
Receiving School Code
Phone: (H)
(Bus)
(Cell)
Date of Approval or Denial
/
/
Email
mm
/
dd
/
yy
Parent
Guardian
18-year-old student
q
q
q
6. Indicate reason for requesting a Geographic Exception (Check 1 item and/or briefly explain)
a.
Physical residence
b.
Sibling at same school c.
Child of school staff member
q
q
q
d.
Program of study (describe)
q
e.
Other (describe)
q
I understand that falsification of information will be grounds for denial and/or rescinding of this Geographic Exception
Request (Hawaii Revised Statutes (HRS) §710-1063).
Signature
Date
/
/
mm
/
/
yy
dd
SECTION II – To be completed by the public school the child is currently attending OR the Home School for the
incoming kindergarten and new students to the HIDOE system.
School
Date Stamp Receipt of Application
Proof of Residence Document Reviewed
q
List of information regarding special student accommodations (if applicable)
Home/Current School Authorized Official Signature
Date
/
/
mm
/
dd
/
yy
SECTION III – To be completed by the Receiving School
Lottery Number
APPROVED G.E. - To begin on:
/
/
School Name
q
mm
/
dd
/
yy
DENIED G.E. - Filled to capacity
q
Receiving School Authorized Official Signature
Date
/
/
mm
/
/
yy
dd
Request for Review of Denial may be made within ten (10) business days of the postmark date of this notice to the
Complex Area Superintendent (CAS) by submitting Form CHP 13-2. The decision made by the CAS is final.
DISTRIBUTION: WHITE-(Approved) or (Denied)-Receiving School; CANARY-Requester; PINK-Receiving School Complex Area Superintendent;
GOLDENROD-Home School Principal
If Form was downloaded from Website: Colored paper is NOT required for DISTRIBUTION copies.
FORM CHP 13-1, Rev. 12/14, RS 15-0623 (Rev. of RS 13-0857)
CHP13_1_RevDec2014_150623.indd 1
12/1/14 10:08 AM
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