Choice Transfer Request
10903 Gravelly Lake Dr SW • Lakewood WA 98499-1341
(253) 583-5154
WAC 392-137-135, WAC 392-137-140; and
Clover Park School District 3131 Release of Resident Students
Separate form must be completed for each student requesting release of attendance.
Requested District: School Year: 20 to 20
(one year only)
Requested School: New applicant
Program: (if applicable) Renewal applicant
STUDENT INFORMATION (one form per student)
First, Middle, Last:
First, Middle, Last:
Current/Last School Attended:
Birth Date: Grade Level:
(of transfer year)
Phone (1):
Phone (2):
(Parent/Guardian contact if student younger than 18)
Residence Address
City WA, Zip
Mailing Address (If different from residence)
City WA, Zip
Student’s residence has changed
Student’s nancial condition would likely be improved
Student’s educational condition would likely be
Student’s safety concerns would likely be improved
Student’s health condition would likely be improved
Attendance in the nonresident district is more
accessible to the parent/guardian’s place of work
Attendance in the nonresident district is more
accessible to childcare
To enroll in an online school/program
Attendance in the nonresident district is more
accessible to the parent/guardian’s residence
There is a special hardship or detrimental condition
impacting the student or family
To enroll in an alternative school/program
Parent/guardian is an employee of the requested
school district
To enroll in a school with academic options not offered
in this district
To enroll in a school with extracurricular options not
offered in this district
BEHAVIOR (attach sheet with explanation for any yes answers)
Does the student have a record of conviction of crimes, violent or disruptive behavior or gang membership? Yes No
Has this student been expelled or suspended for more than 10 consecutive days? Yes No
Has the student repeatedly failed to comply with requirements for participation in an online school program
such as participating in weekly direct contact with the teacher or monthly progress evaluations?
Yes No
Has the student and/or parent had any formal meetings with school ofcials regarding school attendance issues
in the past two years?
Yes No
Is this student under a court order to attend school, or is a truancy petition in the process of being led? Yes No
The trans
school dis
the effecti
The paren
effective s
If the requ
If a distric
Under the
the stude
of state e
fer request is not complete until
trict, and it has been accepted.
ve start date at the nonresident
t/guardian will be notied by em
tart date or rejection.
est is rejected, the notication
t does not respond to a request
ardian can appeal.
Choice law, the nonresident sc
nt (basic education, special edu
ducational assessments, etc.). L
the resident school district ha
The student remains the resp
ail (or postal mail if an email
will include the reason for the
within 45 days of the request
hool district becomes respon
cation, home/hospital service
egal Reference: RCW 28A.2
s submitted the request to the nonresident
onsibility of the resident school district until
is not provided) of acceptance and the
denial and steps to appeal the decision.
, the request is treated as a denial and the
sible for all matters related to the education of
s, truancy, CEDARS reporting, administration
25.220 through 230.
I certify th
I understa
the nonre
I understa
and that n
I understa
I understa
each year.
I understa
submit a
to the Choic
required to r
effect while
format; no in
The Family Edu
education recor
FERPA gives p
the age of 18 or
Parents or eligi
to provide copie
Schools may ch
information from
at the information provided is a
nd that approval of this request
sident school district’s policy, an
listed in the nonresident schoo
nd that my student must contin
onattendance is subject to trua
nd that I will be responsible for
nt district is required to provide
tion Act of 1973 or the Individu
nd that requests are approved
nd that should my student mov
new request to the new resident school district.
ase: I authorize the resident sc
e Coordinator of the nonresiden
elease my student’s records, I a
my student is enrolled unless I r
formation will be released over
cational Rights and Privacy Act (FERP
ds. The law applies to all schools that r
arents certain rights with respect to their
attends a school beyond the high scho
ble students have the right to inspect an
s of records unless, for reasons such a
arge a fee for copies. Generally, schoo
a student’s education record.
ccurate and complete.
shall be dependent upon the
d rescindment (revoking) of t
l district’s policy.
ue to attend the resident scho
ncy procedures.
providing transportation to an
transportation for the student
als with Disabilities Education
for one school year only, and
e and no longer be a resident
hool district to release any an
t school district. By my signat
m giving my consent to relea
evoke such consent in writing
the phone.
A) (20 U.S.C. § 1232(g); 34 CFR Part
eceive funds under an applicable pro
children’s education records. These
ol level. Students to whom the rights
d review the student’s education rec
s great distance, it is impossible for p
ls must have written permission from
acceptance and rejection standards stated in
his transfer may occur in accordance to the
ol until the effective start date of the transfer
d from school for my student, unless the
with a disability under Section 504 of the
Act (IDEA).
it is my responsibility to complete a new form
of the district, the transfer expires and I must
d all of my student’s educational records
ure I acknowledge that although I am not
se the information. This release will remain in
. Note: Information will be provided in written
99) is a Federal law that protects the privacy of student
gram of the U.S. Department of Education.
rights transfer to the student when he or she reaches
have transferred are “eligible students.”
ords maintained by the school. Schools are not required
arents or eligible students to review the records.
the parent or eligible student in order to release any
I have read and understand that approval of this transfer request is based on the following:
The term shall be for the current school year only.
Special education students must get a release addendum, approved or denied by the director of special education.
Parent/guardian is responsible for providing transportation for the student.
The information provided on this application is current and accurate. Falsication or incomplete information on this
document may be cause for rescinding the request.
Signature of parent/guardian Date
Special Program
Financial Educational
Already Attending: Moved
Child Care Safety
Parent’s Work
Learning Environment
Denied Administrator Signature Date