Form R102 - Custody/guardianship Affidavit Form - Worthington School District printable pdf download

WORTHINGTON SCHOOL DISTRICT

CUSTODY/GUARDIANSHIP AFFIDAVIT Form R102 (green)

I, ___________________________, first being duly sworn, state that I reside in the Worthington

School District and that I have initiated proceedings to obtain legal custody/guardianship of

___________________________, who was born on __________. ORC 23.9 requires that

legal custody provided by the court must be obtained within 60 days.

• PERSON SEEKING LEGAL CUSTODY

Name_________________________________ Relationship to Child____________________

Address ______________________ City _____________________State______ Zip________

Phone ___________Resides in __________ County, within the ______________School District

• PERSON WHO CURRENTLY HAS LEGAL CUSTODY

Name_________________________________ Relationship to Child:___________________

Address ______________________ City _____________________State______ Zip________

Phone ___________Resides in __________ County, within the ______________School District

The student’s prior school of attendance was ______________________________________

located in __________________(city) ________________(state)

I hereby authorize the principal or his/her designee to contact my attorney.

_____________________________ (attorney’s name) at _______________________________

______________________________________________________________________(address)

_________________(phone) regarding the proceeding.

I understand that, if custody/guardianship cannot be proven by a certified court order prior to the

end of the sixty (60) day period, the above-named student will be excluded, unless admission on a

tuition basis is approved. For the student to remain enrolled under this provision, a tuition

application must be completed, submitted to the Superintendent, and the parent(s) must sign an

agreement to prepay tuition on a monthly basis.

______________________________________________________________________________

(Please sign in the presence of a Notary Public)

I swear that the above information is correct to the best of my knowledge

Signature of Applicant

Sworn to and subscribed in my presence this __________day of __________, 20_______

___________________________________

Signature of Notary

______________________________________________________________________________

Based on the information provided, the request for approval to enroll the above-named student under

Section 3313.64(E) O.R.C. is:

( ) APPROVED

( ) DENIED

__________________________________

Principal/Principal Designee

School

Custodial Parent

Attorney

Form R102 - Custody/guardianship Affidavit Form - Worthington School District