Fillable 2021-22 Do not send thi Name of Parent (Wisconsin)

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2021-22 Do not send thi Name of Parent (Wisconsin)

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—OVER—
This application is not valid unless Page 2 and Page 3 are completed.
Wisconsin Department of Public Instruction
PUBLIC SCHOOL OPEN ENROLLMENT—
ALTERNATIVE OPEN ENROLLMENT
APPLICATION PI-9421 (Rev. 06-2021)
INSTRUCTIONS: Submit completed form to the district administrator
of the nonresident school district.
Do not send thi
s form to the
Department of Public Instruction
.
Additional instructions and information are at the end of th
is form.
Date Received in Nonresident
School District Mo./Day/Yr.
Collection of this data is a requirement of s. 118.51, Wisconsin Statutes.
School Year for which Open
Enrollment Exception is Requested
2021-22
I. GENERAL INFORMATION
To be completed by the parent or legal guardian (or the pupil if age 18 or older). The form must be submitted to the nonresident school district with
any required documentation (see back of form).
Legal Name of Pupil First, Middle Initial, Last (A separate form must be completed for each pupil)
Gender
M F
Birthdate Mo./Day/Yr.
Name of Parent or Legal Guardian
Home Phone Area/No.
Work Phone Area/No. Cell Phone Area/No.
Email
Mailing Address City State ZIP
Street Address If different than above
City State ZIP
5-year-old Kindergarten 1 What grade will the pupil be in for the 2021-22 school year?
2 3 4 5 6 7 8 9 10 11 12
PreK or
4-year-old Kindergarten
Early childhood /special education
Only if resident district also offers
program and child is eligible.
Nonresident School District This is the school district the pupil is applying to attend. You may apply to no more than three (3) school districts in a
school year. You must apply to each school district separately. If you submit applications to more than three (3) school districts, all applications will
be invalid.
Optional—If you are applying for the pupil to attend a specific school(s) or program(s) in the nonresident school district, indicate here. Enrollment
in a specific school or program is not guaranteed.
Resident School District This is the school district in which you are currently residing. You must indicate a school district here.
What school district, private school, or home-based education program is the pupil currently attending?
Yes No
Is the pupil currently attending public school in the nonresident school district?
Are siblings of the pupil currently attending public school in the nonresident school district? Name(s)
Are siblings of the pupil also applying at this time to attend the nonresident school district? Name(s)
Does the pupil have an individualized education program (IEP)?
Does the pupil currently receive special education services?
Has the child been referred for a special education evaluation that has not yet been completed?
Parents are responsible for transportation. If the pupil is eligible for free or reduced-price lunches under
the School Lunch Program, you are eligible to apply for reimbursement of transportation costs at the
end of the school year.
Check if you are interested in applying for transportation reimbursement.
No. of Pupils
Transported
No. of Miles
Round Trip
Page 2 PI-9421
II. REASON(S) FOR REQUEST
Choose all that apply
The pupil's resident school board has determined that the pupil has been the victim of a violent criminal offense.
Provide a copy of any finding by the resident school board or a statement by an administrator of the resident school
district explaining the reason for the finding.
Provide an explanation, in Section III, of the circumstances leading to this request.
Date of Resident School
Board Determination
Mo./Day/Yr.
The pupil is or has been homeless in the current or immediately preceding school year.
Provide an explanation, in Section III, of the circumstances leading to this request.
The pupil has been the victim of repeated bullying or harassment.
Provide an explanation, in Section III, of the circumstances leading to this request. Include the date(s) on which the bullying or harassment was
reported to the school district, the person(s) to whom the bullying or harassment was reported, any attempts by the pupil, parent, and/or school
district to halt the bullying or harassment, and the result of these attempts.
The place of residence of the pupil’s parent or guardian and of the pupil has changed as a result of military orders.
Attach a copy of the orders and provide an explanation, in Section III, of circumstances caused by
the issuance of
orders that led to this request.
Date Military Orders
Issued Mo./Day/Yr.
The pupil has moved into this state.
Provide an explanation, in Section III, of the circumstances leading to this request.
Date Pupil Moved into
State Mo./Day/Yr.
The pupil’s residence has changed as a result of a court order or custody agreement or because the pupil was placed in
a foster home or with a person other than the pupil’s parent, or removed from a foster home or from the home of a
person other than the pupil’s parent.
Provide a copy of any court order, custody agreement, or other document pertaining to the change of the pupil’s
residence. Provide an explanation, in Section III, of the circumstances that lead to this request.
Date Pupil Changed
Residence Mo./Day/Yr.
An exception to the open enrollment application period is in the best interest of the pupil.
Provide an explanation, in Section III, of the circumstances leading to this request.
III. EXPLANATION
Provide an explanation of the circumstances leading to this request in the space below.
PI-9421 Page 3
IV. SIGNATURE
BY CHECKING THIS BOX, I AGREE that all information is complete and correct. I am the child’s parent or legal guardian or I am the pupil age
18 or older. I understand that under PI 36.06(2)(a)1, the resident school district will send to the nonresident school district a copy of my child’s
individualized education program (IEP) and/or information about whether my child has been referred for a special education evaluation. I
understand that under s. 118.51(8), Wis. Stats., the resident school district shall provide to the nonresident school district any information about
my child relating to expulsion or expulsion proceedings.
I also understand that under PI 36.12(1)(c) the nonresident district cannot request and a resident district cannot provide any o
ther student
records, including transcripts and attendance records, without my written consent. The nonresident school district may not deny an alternative
application based on a parent’s refusal to consent to release of additional records.
Legal Name of Pupil Name of Parent or Legal Guardian
Signature of Parent or Legal Guardian or Pupil if 18 or Older Signature may be provided electronically.
Date Signed Mo./Day/Yr.
V. INSTRUCTIONS
Instructions to the Parent/Legal Guardian or Adult Pupil
Complete this form, include all attachments, and send or deliver this form
to the nonresident school district to which you are applying. You may
apply to no more than three nonresident school districts in this school
year.
The nonresident school district may deny the application for the same
reasons it may deny an application submitted during the open enrollment
application period. There is no provision in the statutes for parents to
appeal a nonresident school district’s decision.
The resident school district may only deny an application for the following
reasons:
• The resident school district determines that the criteria relied on by
the applicant does not apply to the pupil.
• The resident school district does not agree that the transfer is in the
bes
t interest of the pupil
.
The resident district may not deny an application if it is based on the
resident school district's finding that the pupil has been the victim of a
violent crime.
The pupil’s parent may appeal the resident district’s decision to the
department within 30 days after the decision.
Instructions to the Nonresident School District
Immediately upon receipt of this form, enter the applic
ation into the
open enrollment database. If the parent provided additional
documentation, send a copy of the application and all attachments to the
resident school district indicated on the application.
Within 20 days of receiving the form, notify the parent, in writing, whether
the application is approved or denied.
The nonresident school district may deny the application for the same
reasons it may deny an application submitted during the regular open
enrollment application period.
The nonresident school district may deny the application if it does not
agree that the transfer is in the best interest of the pupil.
Instructions to the Resident School District
Within 10 calendar days of receiving this form, send a copy of the
individualized education program (IEP) if the pupil is a child with a
disability, and of any expulsion order or information about any pending
disciplinary proceeding concerning the pupil.
Within 20 calendar days of receiving this form, notify the parent, in
writing, if the application is denied.
The resident school district may only deny an application for the following
reasons:
• The resident school district determines that the criteria relied on by
the applicant does not apply to the pupil.
• The resident school district does not agree that the transfer is in t
he
best interest of the pupil.
T
he resident district may not deny an application if it is based on the
resident school district's finding that the pupil has been the victim of a
violent crime.
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2021-22 Do not send thi Name of Parent (Wisconsin)

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Completed 18 August 2021

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