STUDENT #
☐ PARENT
☐ ACCEPTING SCHOOL
REVISED 11/29/2018
Reason for Request:
REQUESTED SCHOOL:
SCHOOL YEAR:
INSTRUCTIONS: Submit this completed form to the Student Placement office by email at studentplacement@bsd405.org or in person.
The Student Placement Office will approve or deny this transfer request. If you receive an approved copy, enroll at the requested school.
M
STREET APT #
DATE OF BIRTH
GRADE LEVEL OF
TRANSFER YEAR
GENDER
CITY
STATE
ZIP
PARENT/GUARDIAN EMAIL ADDRESS
HOME
HOME CELL WORK
NEW ADDRESS - MOVE-IN DATE
PARENT/GUARDIAN PHONE 1:
Complete current school year
Complete school level (elementary, middle, high school)
CELL WORK
PHONE 2:
Sibling at same school
Explain your reasons for this transfer request: __________________________________________________________
__________________________________________________________________________________________
Identify any special activities or unique educational programs that your student participated in at his/her current school
☐ IEP ☐ ELL ☐ 504 Plan ☐ Advanced Learning ☐ ISA ☐Spanish DL Program ☐ Mandarin DL Program ☐ Other
If this Transfer Request is approved I understand the following:
Transportation is the responsibility of the parent/guardian for elementary and middle school students.
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
Approved transfers may be discontinued for the following reasons:
a)
If adequate space is no longer available at the proper grade level because of an unusual increase in enrollment
including increases resulting from attendance-area boundary changes.
b)
If the student is excessively tardy or truant, or engages in frequent misconduct, and/or disruptive behavior in violation
of school rules that indicates the student is not being successful at the school.
Once approved a transfer normally continues until the student completes the educational
program at the current level of enrollment (elementary, middle, high school), unless approved for completion of school year only.
Information below to be completed only by the Superintendent's Designee
SIGNATURE OF SUPERINTENDENT'S DESIGNEE
DATE
STUDENT'S LAST NAME FIRST NAME
HOME / ATTENDANCE AREA SCHOOL
PLEASE PRINT: NAME OF PARENT/GUARDIAN OR STUDENT IF OVER 18
SIGNATURE OF
(PARENT/GUARDIAN OR STUDENT IF OVER 18)
DATE
NAME OF SIBLING
3120P - Exhibit D
CURRENT SCHOOL:
School/Location:
For Student Placement use only
TRANSFER REQUEST
For Bellevue School District Resident Students
Parent/guardian is a BSD FT Employee
BSD ID #:
EMAILED
AA schools______/______/______
Employment verified_________(initials)
X
F
☐ Discipline & Attendance review
☐ DENIED
- The school requested above is at capacity and unable to accept students from outside their attendance area
N otes :
SIGNATURE OF SUPERINTENDENT'S DESIGNEE
DATE
☐
ADD TO WAITING LIST
☐ APPROVED
☐ APPROVED Reconsidered action on this application
☐
APPROVED for completion of school year only
☐ APPROVED with the following conditions___________________________________________________________________________
SCANNED _________
UPLOADED ________
T-CODE___________
ADDRESS _________
click to sign
signature
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