Affidavit D State Of North Carolina
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1
2NOTE:
If the student’s parent or legal guardian has retained legal custody
AFFIDAVIT D
of this student, then the affidavit procedures for parents/legal
guardians and adult caregivers (Affidavits B and C) must be
followed in lieu of this document. If the affidavit requirements
cannot be met then the student will be considered as an out-of- district
transfer.
STATE OF NORTH CAROLINA )
COUNTY OF HENDERSON
)
Please Print or Type
IN THE MATTER OF
STATEMENT OF AUTHORITY
Full Name of Student
AND RESPONSIBILITY
BY LEGAL CUSTODIAN AND BY
Address of Group Home, Foster Home, or Facility
RESPONSIBLE ADULT
City
State
Zip
(LICENSED GROUP HOME, FOSTER
HOME, OR SIMILAR FACILITY)
Current Grade
Last School Attended
(G.S. 115C-366(a6))
Sex
Date of Birth
Age
Printed Name of Responsible Adult
We hereby certify and represent that the above-referenced student has been placed with
____________________________________________________________________________________
(Name of group home, foster home, or similar facility)
by _____________________________________________________________________________, and
(Name of individual or government agency)
1.
The individual or government agency listed above who has placed this student with the above-
referenced group home, foster home or similar facility has been awarded legal custody of the
student by a court (attach court order).
2.
The group home / foster home / facility has been approved as a “licensed facility” by the State of
North Carolina.
3.
The undersigned responsible adult resides or is employed within the boundaries of the Henderson
County School District.
4.
The undersigned responsible adult has the authority and hereby accepts the responsibility for
educational decisions for the student, including enrolling the student, receiving and responding to
notices of discipline under G.S. 115C-391, attending conferences with school personnel, acting as
"parent" in connection with all special education decisions, granting permission for school-related
activities, granting permission for emergency medical care, receiving and taking appropriate
action in connection with student records, and any other decisions or actions recommended or
required by the school in connection with this student.
5.
Student is not currently under suspension or expulsion from attendance at a private or public
school in this or any other state and has never been convicted of a felony in this or any other state.
R&S 534656-1
Henderson County Public Schools 7.16.07dlj
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