Choice Transfer Request - Camas School District
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2 New Request
Resident District: _______________
Choice Transfer Request
Resident School: ________________
Renewal
Requested District: ___________________________________________
School Year: 20___ to 20___
(one year only)
Requested School: ___________________________________________
Start Date: ___________
(if mid‐year transfer)
Program:
_________________________________________
End Date: ___________
(if applicable)
STUDENT INFORMATION (one form per student)
Student:____________________________________________________
Birth Date: __________ Grade Level: _____
First Middle Last
(of transfer year)
Parent/Guardian contact (if student younger than 18):
Parent/Guardian: ____________________________________________
PLEASE PRINT
(Required if student is younger than 18 at the time of this request)
Email: _______________________________
Phone (1): _________________
Current or Last School Attended: ________________________________
Phone (2): _________________
Residence Address
Mailing Address (if different from residence)
_______________________________________________
_______________________________________________
_______________________________, WA ___________
_______________________________, WA ___________
City Zip
City Zip
The following information is used to determine availability in the designated programs.
Is your student currently being tested for or participating in any of the following programs: Special Education* (IEP), Gifted, Section 504,
Bilingual (ELL), Title I/LAP? Yes No If yes, which program? ________________________________
*If Special Education, provide a copy of the IEP to requested school district.
REASON FOR REQUEST (please choose only one)
The student’s financial, educational, safety, or health conditions would likely be improved.
Attendance in the nonresident district is more accessible to the parent’s/guardian’s place of work or to the location of child care.
There is a special hardship or detrimental condition.
The purpose of the transfer is for enrollment in an online course or school program offered by an OSPI‐approved provider.
Parent/guardian is an employee with the requested school district.
Comments: _________________________________________________________________________________________________
BEHAVIOR (attach sheet with explanation for any yes answers)
Yes No
Does the student have a record of conviction of crimes, violent or disruptive behavior or gang membership?
Yes No
Has this student been expelled or suspended for more than 10 consecutive days?
Yes No
Has the student repeatedly failed to comply with requirements for participation in an online school program, such
as participating in weekly direct contact with the teacher or monthly progress evaluations?
Yes No
Has the student and/or parent had any formal meetings with school officials regarding school attendance issues in
the past two years?
Yes No
Is this student under a court order to attend school or is a truancy petition in the process of being filed?
Please see second page for important notices, acknowledgements, and signature.
3/2016
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