2019- 2020
REQUESTED SCHOOL:
THIS REQUEST IS FOR SCHOOL YEAR:
2020 - 2021
IN STRUCTIONS: 1)
Submit this completed form to the Student Placement Office by email at studentplacement@bsd405.org or in person.
2) Submit a Choice Transfer Request to your Resident District. The Student Placement office will approve or deny this transfer request
.
3) If you receive an approved copy, enroll at the requested school.
DATE OF BIRTH
STUDENT'S LAST NAME
FIRST NAME
GRADE LEVEL OF
TRANSFER YEAR
GENDER
F
M
, WA
ZIP CODE
PLEASE PRINT: NAME OF PARENT/GUARDIAN OR STUDENT IF OVER 18
DATE
SIGNATURE OF (PARENT/GUARDIAN OR STUDENT IF OVER 18)
☐ APPROVED
Information below to be completed only by the Superintendent's Designee
PARENT'S EMAIL or student's email if over 18
PARENT'S PHONE 1:
HOME CELL WORK
CURRENT OR LAST SCHOOL ATTENDED
STUDENT'S RESIDENT SCHOOL DISTRICT
Financial Safety Health
Location of Childcare or Parent’s Workplace
Parent/guardian is BSD FT employee
School/Location:
Identify the education programs that your student participated in at his/her last school:
IEP ELL 504 Plan
Please answer each question below - false or inaccurate information will be cause for denial or revocation of this application:
Has your student had problems with tardiness, or truancy at his/her last school? Yes No
Has your student ever been suspended, involuntarily removed, or expelled from school? Yes No
Does your student have any history of convictions for offenses or crimes, violence or disruptive behavior, or gang membership? Yes No
If “Yes” for any of the above, please explain:
As the parent/guardian of (PLEASE PRINT STUDENT'S NAME) , I hereby certify that the information
provided herein is true and correct to the best of my knowledge. I understand that any significant omission or inaccuracy in this information may
be a separate basis for the denial or revocation of this application. Pursuant to District Policy 3141, I further understand the following:
Secondary transfer students are not eligible to participate in varsity athletics for one year after being enrolled in their new school.
WIAA eligibility rules apply to all secondary students who transfer between schools.
Transportation is the responsibility of the parent/guardian;
Enrollment in the Bellevue School District is subject to termination in certain situations, such as if your student is excessively tardy or truant,
frequently engages in disruptive behavior (non-resident students need to be successful in the District to continue enrollment);
A new application process is required if, once admitted, the nonresident student seeks to change programs or schools from that to which the student
was admitted; and
Certain schools and programs may have no capacity for nonresidents and, therefore, may be unable to accept nonresident students
PARENT'S PHONE 2:
HOME CELL WORK
For Student Placement use only
If approved this will certify the acceptance of the above named student, subject to Bellevue school District policies and any state statutory or regulatory requirements.
STUDENT #
3141P - Exhibit A
INTERDISTRICT TRANSFER APPLICATION
For Nonresident Students
Please select one
SCANNED _________
UPLOADED ________
T-CODE___________
ADDRESS _________
Hardship Complete current school year
The family will be moving into Bellevue School District
SIGNATURE OF SUPERINTENDENT'S DESIGNEE
DATE
☐ PARENT
☐ SCHOOL REGISTRAR/OFFICE MANAGER
REVISED 11/1/42019
EMAILED
Employment verified___________(initials)
☐ APPROVED WITH THE FOLLOWING CONDITIONS :
X
BSD ID#:
☐ DENIED
- The school requested above is at capacity and unable to accept students from outside their attendance area
Note:
☐
ADD TO WAITING LIST
FTE /HRS per wk:
REASON FOR REQUEST:
What is your current housing situation? Own
Rent
Other (Specify) __________________________________________
STUDENT'S RESIDENCE ADDRESS APT # CITY
☐ Discipline & Attendance review
click to sign
signature
click to edit
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