Non Resident Enrollment School Verification Form - University Place ...

University Place School District 2009-103717 Grandview Drive W, University Place, WA 98466Phone: 253-566-5600; Fax: 253-566-5607Non-resident Enrollment School VerificationParent/Guardian: Please have the information below completed by your child’s current school and return withthe non-resident enrollment form and release paperwork. Applications for enrollment in UPSD will not beconsidered without this information.Student Name:______________________________________________ Grade in 2009-10__________________Student Resident Address:______________________________________________________________________Last School Attended, School Name:_________________________________ Phone number:________________City:_________________________ State:__________ Enrolled from:________to________As part of the application process for non-resident students attending school in University Place School District,students are asked to provide information on current academic progress/grades, attendance and discipline. Weappreciate your assistance in providing this information.Does Student have a history of any of the following?1. Placement in special education program Yes No2. Special accommodations for a 504 plan Yes NoIf yes, please provide copy of current IEP or 504 plan.3. Unpaid fines or fee from other schools Yes No4. Past, current, or pending suspensions from school of 10 or more days Yes No5. Past, current, or pending expulsions from school Yes NoIf you answered “YES” to any of the above, provide explanation on back.Grades and AttendancePlease attach most current grade/progress, and attendance report for the above named student.Students in grade 9-11 also need to provide a current transcript.Additional Comments/Considerations:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Completed By:Name _____________________________________________________________School/District ______________________________________________________Title ______________________Phone _____________________UPSD Student Transfers Office 1/27/09

Verification and Student History – EXPLANATIONUse this for explanation of any conditions marked as “YES” on the other side of this form.**Please also provide a discipline history report from current school if yes was circled for #4 or #5.**Item #ExplanationName of person completing this form (please print)____________________________________Signature____________________________________ Date______________________________Relationship to student (circle one) Parent/guardianStudent (if over 18 yrs old)UPSD Student Transfers Office 1/27/09