Request For Student Reassignment/admission Of Nondomiciiary Student Form
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1
22016 – 2017 School Year
Application Deadline: March 1, 2016 – June 1, 2016
SC Policy 4150
Revised: 3/2014
Stokes County Schools
Request for Student Reassignment/Admission of Nondomiciiary Student
One copy of this form must be completed for each student and submitted to the Office of the Superintendent, Stokes County
Schools, P.O. Box 50, Danbury, NC 27016, Attn: Ann Sliger. This form must be completed in accordance with timelines
specified in Policy 4150. Please review carefully all requirements for reassignment/admission contained in Policy 4150.
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GENERAL INFORMATION – Application for student reassignment/admission must be made each school year.
I.
Student: _________________________________________________ Age: ________ Grade: ________ (2016/2017)
Parents/Guardian: ______________________________________________
Telephone: __________________________
Mailing Address: ____________________________________ City: _____________________ State: _____ Zip: _________
Identify Residence Location (if different from mailing address): ________________________________________________
School Attended 2015-2016 ______________________________________________________________
Names of siblings attending Stokes County Schools ___________________________________________
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II.
TYPE OF REASSIGNMENT REQUESTED. Please complete all information on your chosen type of reassignment.
_____
In-County Reassignment.
From: _______________________________ School
To: __________________________________ School
Has student previously been reassigned outside his/her attendance area?
Yes or No
If yes, From: __________________________School
To: ___________________________School
_____
Release from Stokes County Schools to __________________________ School System.
_____
Admission to Stokes County Schools from _________________________________________ School System.
To: _________________________________________ School
(Please attach copy of release from system where student is legally domiciled.)
Tuition is payable upon approval of admission request.
Is student currently under suspension from another school? _____ Yes _____ No
Has student ever been convicted of a felony in any state?
_____ Yes _____ No
Is student receiving Exceptional Children’s services at his/her present school? ____ Yes ____ No
If yes, what type of services? _____________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
If yes, please submit with this request form a copy of your child’s IEP or 504 Plan. Additional information may be
requested. To the extent practical the Stokes County Schools provides special education programs and services in
each attendance district. However, in order to provide a reasonable accommodation of a child’s needs, he/she may
be assigned to a school within another attendance district. For applicants not domiciled in Stokes County, admission
may be conditioned upon the successful negotiation of an inter-local agreement with the domiciliary school district
for the child’s education
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III.
REASON(S) FOR REQUEST: Please check all applicable reasons.
_____
Change in residence or family status. (See requirements in policy)
_____
Medical hardship, including physical or mental disabilities. (Complete Part IV.)
_____
Parents or legal guardians are full time/permanent employees of Stokes County Schools.
_____
Documented proof of need for student to attend another school. (Complete Part IV.)
th
_____
Child care for a student not yet entering 6
grade. (Complete Part V.)
_____
Documented proof of hardship. (Complete Part IV.)
Please explain in detail the reason(s) for this request. Please complete Part IV and/or Part V (if required), and attach
supporting documentation.
Explanation of reason(s):________________________________________________________________________________
____________________________________________________________________________________________________
Failure to complete form in its entirety will result in a delay of processing.
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