Fillable BELLEVUE SCHOOL DISTRICT No. 405 (Bellevue School District)

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BELLEVUE SCHOOL DISTRICT No. 405 (Bellevue School District)

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BELLEVUE SCHOOL DISTRICT No. 405
P.O. BOX 90010 BELLEVUE, WASHINGTON 98009-9010
New Request
Renewal
REQUEST FOR PART-TIME ATTENDANCE OR ANCILLARY SERVICES FROM A
PRIVATE SCHOOL STUDENT OR A STUDENT RECEIVING HOME-BASED INSTRUCTION
STREET
APT #
HOME / ATTENDANCE AREA SCHOOL STUDENT ID
CITY
STATE
ZIP
COUNSELOR
EMAIL ADDRESS
PHONE :
HOME CELL WORK
R
EQUEST BY PRIVATE SCHOOL STUDENT ☐
__________
______
______________________
_
As the parent of ______________________________ , I attest that the services requested are not
provided in the private school that my child attends.
__________________________________
REQUEST BY HOME SCHOOL STUDENT ☐ REQUEST FOR SPECIAL EDUCATION SERVICES ☐
ANCILLARY SERVICES REQUESTED:
REQUESTED COURSE(S) AND START DATE(S) STUDENT WANTS TO PARTICIPATE:
Course/Subject:_______________________________ Start date: ______________________
Course/Subject:_______________________________ Start date: ______________________
Course/Subject:_______________________________ Start date: ______________________
Course/Subject:_______________________________ Start date: ______________________
Course/Subject:_______________________________ Start date: ______________________
Return form completed and signed to:
APPROVAL OF STUDENT PLACEMENT SUPERVISOR
DATE
STUDENT LAST NAME
FIRST NAME
DATE OF BIRTH
GRADE LEVEL
(of transfer year)
GENDER
PLEASE PRINT PARENT/GUARDIAN NAME
SIGNATURE (PARENT/GUARDIAN OR ADULT STUDENT)
DATE
NAME OF PRIVATE SCHOOL
Bellevue School District, Superintendent Designee
Student Placement, P.O. Box 90010, Bellevue, WA 98009-9010
PH: 425-456-4200 EMAIL: StudentPlacement@bsd405.org
STUDENT PLACEMENT DISTRIBUTION:
☐
SCHOOL CO
UNSELO
R
☐
SC
HOOL R
EGISTRAR ☐ SPECIAL EDUCATION ☐ ADVANCED LEARNING PROGRAMS
3114P Exhibit A
PARENT SIGNATURE
☐ IF SERVICES ARE SUPPORTED BY CURRENT IEP & EVALUATION
Approvals are contingent upon the following conditions:
☐ IF ALL PREREQUISITES ARE MET
☐ IF STUDENT QUALIFIES FOR ADVANCED LEARNING SERVICES
☐ ES PRINCIPAL ☐
ES OFFICE MANAGER ☐ PARENT ☐ ATHLETIC DIRECTOR
SCHOOL YEAR_____________________
*
*
Bellevue School District 11/05/2019
*
DECLARATION OF INTENT TO HOME SCHOOL RECEIVED ☐
☐ M ☐ F ☐ X
2019-2020
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BELLEVUE SCHOOL DISTRICT No. 405 (Bellevue School District)

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Completed 26 November 2020

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