Adopted: May 1999
Revised: October 2024
Download 502.4.4P - Student Transfers: Daycare for Students in Grades K-5
INSTRUCTIONS TO PARENTS/GUARDIANS:
- This form must be completed for the following purposes:
1. For a District 196 resident elementary school student (grades k-5) who transfers from one District 196 elementary school to another because of the location of the student's daycare provider, OR
2. For a nonresident elementary school student (grades k-5) who needs transportation to and/or from daycare within District 196 boundaries. This form must be submitted along with Procedure 502.4.1P, Application to Participate in the State Enrollment Options Program.
- Forms from nonresidents must be received by the District 196 Student Information Supervisor by December 15 for the following school year.
- Transportation services are provided within the parameters set by district policies and regulations.
A NEW FORM MUST BE COMPLETED FOR EACH SCHOOL YEAR AND
FOR ANY CHANGE DURING THE SCHOOL YEAR.
Please print. Complete a separate form for each student each school year.
Student's name (last, first, middle) Current grade level (or, if summer, grade level in coming year)
Student's ID number Parent/guardian name (last, first, middle)
Address (street, city, zip code)
( ) ( ) ( )
Parent or guardian telephone number(s) (home) (work) (cell/pager)
This student fits in one of the categories checked below:
Transfer from one District 196 elementary school to another because of location of daycare provider
Transfer from outside District 196 to a District 196 elementary school (with a completed Procedure 502.4.1P, Application to Participate in the State Enrollment Options Program)
Name of district and school of residence School requested to attend
Daycare provider
( )
Daycare provider’s name Phone
Address (street, city, zip code)
Person to contact in an emergency
( )
Name and relationship Phone
Transportation requested because location of daycare provider noted above qualifies student for transportation service?
Yes No
If yes: I would like my child to be picked up ____ and/or dropped off ____ at the daycare address above (check appropriate response[s]). I am also submitting Procedure 707.5.2P, Transportation for Elementary School Students in Daycare at this time.
Requested date for transfer and/or transportation to begin:
Additional information
I understand it is my responsibility to bring my child to this daycare location and to take my child from this daycare location to my residence. I understand that, if my child qualifies for transportation, the school district’s responsibility will be to transport my child from the daycare location to school and/or from school to the daycare location.
__________________________________________________ _____________________
Parent/guardian signature Date
Send this completed form to: Student Information Supervisor
Independent School District 196
3455 153rd Street West
Rosemount, MN 55068
DISTRICT USE ONLY
Procedure 502.4.1P: received __ yes __ no approved __ yes __ no Date received
______________________________________________________
Signature of student information supervisor
Distribution:
|
Parent, guardian or adult student Student's cumulative folder |
|
Principal of school of residence Principal of requested school Transportation Department |