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Kent County Public Schools
Application for Out-of-Zone Placement
Part 1 Student Information
Part 2 Mother/Guardian Information Part 3 Father/Guardian Information
Part 4 Request
Part 4 Request This is a request for (circle one): new placement continuation of placement
Part 4 - Request
Part 5 Childcare Verification (Must be completed if this is the reason for the request)
Part 5 Childcare Verification (Must be completed if this is the reason for the request)
Part 6 Parent Verification
Part 7 School Assignment Decision(For use by Student Services Only)
05/20
05/2018
Student must be enrolled in required KCPS attendance zone school prior to submitting this application.
Please return completed form to the principal of your childs home school.
Applications submitted after June 30th will not be accepted unless the student is new to KCPS or there is a bona fide emergency or event that could not have been foreseen prior to June 30th.
Childcare information/verification must be complete if that is the reason for the request.
Continued approval is not guaranteed from year to year. Applications must be submitted and renewed yearly for continued attendance out of zone.
Student Name:Student DOB:Current Grade:Home Street Address (where student resides):City/State/Zip:
Father/Guardian:Street Address:City/State/Zip:Home Phone:Work Phone:Cell Phone:
This is a request for: (please check one)
_____ new placement
_____ continuation of current placement
Mother/Guardian:Street Address:City/State/Zip:Home Phone:Work Phone:Cell Phone:
Students Assigned Home School:Requested School:This request is for the 20___ - 20___ school yearGrade of student during requested year:Reason for Request: (Attach a separate sheet if needed)
Name of person providing care:Street Address:City/State/Zip:Home Phone: Cell Phone:I hereby verify that I will be providing childcare services for the student who is requesting an out-of-zone placement in KCPS.
Signature of Childcare provider/Date:
I hereby declare and affirm under penalties of perjury that the information provided above is true and correct to the best of my information, knowledge, and belief. I understand and agree that if false information is provided, the out-of-zone placement will be denied or revoked.
Parent/Guardian Name (Printed):Parent/Guardian Signature/Date:
Top of Form
Placement: _____ Approved _____ Denied Reason for denial: PRIVATE "" MACROBUTTON HTMLDirect class size PRIVATE "" MACROBUTTON HTMLDirect does not meet guidelines
_____Wait List PRIVATE "" MACROBUTTON HTMLDirect lack of documentation PRIVATE "" MACROBUTTON HTMLDirect false information PRIVATE "" MACROBUTTON HTMLDirect missed deadline PRIVATE "" MACROBUTTON HTMLDirect noncompliance w/school rules PRIVATE "" MACROBUTTON HTMLDirect past attendance issues
Bottom of Form
Supervisor of Student Services Signature/Date:
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