Request For Interdistrict Transfer Agreement Permit Form

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This form is for residents of
SAN FRANCISCO UNIFIED SCHOOL DISTRICT
San Francisco who wish to
EDUCATIONAL PLACEMENT CENTER
School year 20____ - 20 ____
attend school in another
555 FRANKLIN STREET, ROOM 100
district.
SAN FRANCISCO, CA 94102
New Request______
Telephone: (415) 241-6085
Renewed Request______
REQUEST FOR INTERDISTRICT TRANSFER AGREEMENT PERMIT
Applying for
Student name_____________________________________________Birthdate_____________ Grade________ Race/Ethnicity_____
Last
First
Address _______________________________________________________________________Home Phone # __________________
Number
Street
Apt
Zip
Current School ______________________ Requested School ______________________ District requested____________________
Is student receiving Special Education Services or other Special Services?
Yes
No.
If yes, is student in
Resource Specialist Program
Special Day Class
Other___________________ I.E.P. must be attached
Reason for Request: ___________________________________________________________________________________ _________
______________________________________________________________________________________________________________
If request is for Childcare or Employment reasons, complete the following:
Childcare Provider _____________________________________
Employer Name______________________________________
Address_______________________________________________
Address_______________________________________________
City, Zip______________________________________________
City, Zip______________________________________________
Phone No:_____________________________________________
Phone No _____________________________________________
Work schedule_________________________________________
NOTE: IMPORTANT INFORMATION
1.
This Agreement covers only one school year. You must reapply annually.
2.
If an Interdistrict Contract has been signed by both districts, the district of attendance may reserve the right to revoke this permit for
any student whose behavior, citizenship, attendance and/or academic progress fails to meet their standards
MOTHER/GUARDIAN (print)____________________________ FATHER/GUARDIAN (print)____________________________
Work/Cell phone #____________________________
Work/Cell phone #_____________________________
PARENT/GUARDIAN SIGNATURE:___________________________________________________ Date_____________________
 District of attendance to claim ADA for revenue purposes (no tuition billed) for General Education students.
 For students receiving Special Education Services, an InterSELPA agreement will need to be signed by the SELPAs to which both the district
of attendance and the district of residence are members prior to this Interdistrict Permit’s approval.
If this student requires new or additional special education services, or change in service, subsequent to date of approval of this permit, SFUSD
MUST BE informed prior to the IEP meeting, and invited to the IEP meeting, and this permit will need to be reviewed.
FOR DISTRICT OF ATTENDANCE USE ONLY ONLY
This agreement, made and entered into this ______ day of _____________, 20___, pursuant to Education Code chapter 5, Section 46600, by the
Governing Board of the San Francisco Unified school District of San Francisco County, and the __________________________________________
School
District
of
_________________________
County
hereby
give
permission
for
the
above-named
pupil
to
attend
____________________________ school in the Second-named District during the school year ending June ______, 20____.
Taken by:________ Date:__________
HO#_______________________
District of Residence (S.F.U.S.D.)
District of Attendance:__________________________________
____________________________________________________________
____________________________________________________________
Signature (Authorized Official)
Signature (Authorized Official)
Title________________________________________________
Title________________________________________________
Date___________ Approve_________
Deny________
Date__________ Approve________ Deny________
Non-Discrimination Policy
San Francisco Unified School District programs, activities, and practices shall be free from discrimination based on actual or perceived race, color, ancestry, national origin, ethnic group identification, age, religion,
marital or parental status, physical or mental disability, sex, sexual orientation, gender, gender identity, or gender expression; or on the basis of a person’s association with a person or group with one or more of
these actual or perceived characteristics.
If you believe you have been discriminated against, immediately contact the school site principal and/or Executive Director of the Office of Equity, Ruth Diep, at (415) 355-7334 or diepr@sfusd.edu. A copy of
SFUSD’s uniform complaint policy is available upon request.
Reason for Denial:
Appropriate placement available in San Francisco
Other_________________________________________________________________
Distribution: White -SFUSD
Gold- District of Attendance
Pink- Parent (after signed by both districts)

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