REQUEST FOR SUPERINTENDENT’S AGREEMENT RSU #34 – OLD TOWN, ALTON, BRADLEY
Note: Continued enrollment of non-resident students will be contingent on the student
demonstrating the highest level of scholarship and deportment.
RSU #34 - 156 Oak Street - Old Town, Maine 04468 - 827-7171 phone - 827-3922 fax
form updated 2013
_____________________________ _______________ ________________________________
Students Name Date of Birth District of Home Residence
______________________________ ____________________________________ _____________
Parent/ Guardian Physical Address w/ City Phone number
_______________________________________________ ______________ ______
School (District) You Wish the Student to Attend School Year Grade
Complete all the sections below:
A. Residence Information:
a. Name of head of household _____________________________________________
b. Relationship Parent/Guardian Relative Other – Please explain _______________
c. Address ______________________________________ Phone number_________________
B. Educational Needs:
a. Does your child have any special education needs? Yes No If yes, please
explain:____________________________________________________________________
__________________________________________________________________________
C. Reason for transfer of Student:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Your signature below acknowledges you understand that if this placement is approved by the
Superintendent of Schools, it will be for one year at a time. Application for renewal must be made
annually. It is the parent/guardian’s responsibility to seek enrollment of the student, unless the student is
18 years of age or older.
_________________________________________ ________________________________
Student Signature (if 18 years of age or older) Parent/Guardian Signature
_______________________________________ __________
Signature of Resident District Superintendent Approved Denied Date
_______________________________________ __________
Signature of Receiving District Superintendent Approved Denied Date
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